Doug Brunk

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

“There are several areas of overlap between the skin and the GI tract,” Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. Diseases of the GI tract that commonly involve some form of cutaneous manifestation include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity “really depends on the underlying molecular defect,” said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego. “GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type,” [in which] almost 80% of children are affected [by dysphagia].”

Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. “But when you palpate [them], they are soft and compressible.”

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

“Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon,” said Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy “facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment.”

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema.

The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Marked by a genetically determined intolerance to gluten, classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method.

“In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate,” Dr. Dohil said. “Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for.”

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation of celiac disease. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous. It commonly occurs in the trunk area and on the back of the forearm and elbow. These lesions “are fairly uncommon in children, and when they do occur they may not be very distinct,” she said. Recently a variety of skin conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. However, since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis. Treatment includes dapsone and a gluten-free diet for life.

Dr. Dohil reported that she had no relevant disclosures to make.

GI disease in epidermolysis bullosa is common, particularly in the recessive dystrophic type. DR. DOHIL

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

“There are several areas of overlap between the skin and the GI tract,” Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. Diseases of the GI tract that commonly involve some form of cutaneous manifestation include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity “really depends on the underlying molecular defect,” said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego. “GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type,” [in which] almost 80% of children are affected [by dysphagia].”

Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. “But when you palpate [them], they are soft and compressible.”

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

“Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon,” said Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy “facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment.”

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema.

The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Marked by a genetically determined intolerance to gluten, classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method.

“In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate,” Dr. Dohil said. “Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for.”

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation of celiac disease. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous. It commonly occurs in the trunk area and on the back of the forearm and elbow. These lesions “are fairly uncommon in children, and when they do occur they may not be very distinct,” she said. Recently a variety of skin conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. However, since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis. Treatment includes dapsone and a gluten-free diet for life.

Dr. Dohil reported that she had no relevant disclosures to make.

GI disease in epidermolysis bullosa is common, particularly in the recessive dystrophic type. DR. DOHIL

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

“There are several areas of overlap between the skin and the GI tract,” Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. Diseases of the GI tract that commonly involve some form of cutaneous manifestation include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity “really depends on the underlying molecular defect,” said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego. “GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type,” [in which] almost 80% of children are affected [by dysphagia].”

Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. “But when you palpate [them], they are soft and compressible.”

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

“Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon,” said Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy “facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment.”

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema.

The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Marked by a genetically determined intolerance to gluten, classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method.

“In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate,” Dr. Dohil said. “Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for.”

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation of celiac disease. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous. It commonly occurs in the trunk area and on the back of the forearm and elbow. These lesions “are fairly uncommon in children, and when they do occur they may not be very distinct,” she said. Recently a variety of skin conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. However, since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis. Treatment includes dapsone and a gluten-free diet for life.

Dr. Dohil reported that she had no relevant disclosures to make.

GI disease in epidermolysis bullosa is common, particularly in the recessive dystrophic type. DR. DOHIL

A production delay has caused Merck & Co. to temporarily stop accepting orders for the company's pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008, while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention has reported that the pediatric formulation and adult formulation of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix), “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the company's pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008, while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention has reported that the pediatric formulation and adult formulation of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix), “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the company's pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008, while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention has reported that the pediatric formulation and adult formulation of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix), “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

SAN DIEGO — Two studies represent “an opportunity to do some useful intervention research in shaken baby syndrome or abusive head trauma,” Janet Saul, Ph.D., said at a conference sponsored by Rady Children's Hospital, San Diego.

The first, led by Dr. Mark S. Dias, a pediatric neurosurgeon at Pennsylvania State University, Hershey, will test the efficacy of a hospital-based intervention. Components include a video and brochure about shaken baby syndrome, discussion about it with a clinician, posters, and a commitment statement for new parents to sign.

Parents receive four messages: crying is normal; there are ways to calm a baby; there are ways to calm yourself; it's important to select other caregivers.

Also, half the counties in Central Pennsylvania will receive a “booster” session for parents who come to pediatric offices for 2-, 4-, and 6-month immunization visits.

In North Carolina, researchers led by Dr. Desmond Runyan of the department of social medicine at the University of North Carolina at Chapel Hill are conducting a statewide preventive intervention that prepares parents to deal safely and explicitly with crying. Nurses in charge of nurseries in hospitals and birthing centers will show parents a DVD about the normalcy of crying and the ways to respond. The DVD will be given to parents to be shared with baby sitters and day care providers.

Pediatricians and family physicians also are being asked to deliver the same DVD and information to mothers at either prenatal care visits or the first postnatal visit. A mass media campaign to address infant crying and parent's response to crying is also being developed by the National Center on Shaken Baby Syndrome, said Dr. Saul, a psychologist who is chief of the prevention development and evaluation branch in the division of violence prevention at the CDC's National Center for Injury Prevention and Control, Atlanta.

On the day of injury, a small subdural hemorrhage and subtle edema are seen.

Four weeks later, atrophy is seen, due to brain damage sustained by the injury. Images Courtesy Dr. Mark S. Dias

Campylobacter and Salmonella infections are the most common contributors to the incidence of reactive arthritis related to foodborne illness, judging from results of a population-based study in two states.

Dr. John M. Townes of Oregon Health and Science University, Portland, and associates conducted telephone interviews with residents of Minnesota and Oregon who had culture-confirmed Campylobacter, Escherichia coli O157, Salmonella, Shigella, and Yersinia infections reported to the Centers for Disease Control and Prevention's Foodborne Disease Active Surveillance Network between 2002 and 2004. Parents or legal guardians provided proxy interviews for those younger than 18 years of age. The researchers invited participants who reported new onset joint pain, joint swelling, back pain, heel pain, and morning stiffness lasting 3 days or more within 8 weeks of culture to complete a detailed questionnaire and physical examination.

Overall, 6,379 culture-confirmed infections were reported to FoodNet in Minnesota and Oregon between 2002 and 2004. The majority were caused by Campylobacter (53%) and Salmonella (30%), followed by E. coli O157 (9%), Shigella (7%), and Yersinia (1%). A total of 4,468 subjects (70%) were interviewed within 2 months of specimen collection. Of these, 575 (13%) reported having new onset of rheumatologic symptoms suggestive of reactive arthritis, which the investigators defined as a history or physical examination findings consistent with monoarthritis, oligoarthritis, dactylitis, enthesitis, or inflammatory back pain without other rheumatologic explanation. The adjusted odds ratio for having these symptoms was higher for subjects aged 18 years and older (OR 2.5), females (OR 1.5), and those who had signs of severe illness including fever, chills, headache, bloody stools, and persistent diarrhea at the time of screening (OR of these symptoms ranged from 1.6 to 2.8). Risk of having new onset of rheumatologic symptoms was not associated with antibiotic use or HLA-B27 (Ann. Rheum. Dis. 2008 Feb. 13 [doi:10.1136/ard.2007.083451

In a subset of 54 patients who met the criteria for the diagnosis of reactive arthritis based on history and physical examinations, Campylobacter was the most common organism of infection (33 cases), followed by Salmonella (17 cases), Shigella (2 cases), E. coli O157 (1 case), and Yersinia (1 case). Most cases were adults (96%) and female (67%). Enthesitis was the most frequent finding on physical exam (48 cases). Arthritis was seen in 10 cases. The incidence of reactive arthritis following culture-confirmed infections of Campylobacter, E. coli O157, Salmonella, Shigella, and Yersinia was estimated to be from 0.6 to 3.1 cases per 100,000 persons.

The researchers acknowledged certain limitations of the study, including the fact that “it is difficult to prove that the rheumatologic symptoms described by our subjects are truly attributable to the antecedent infections,” they reported. “However, by examining a subset of those with subjective symptoms, we were able to provide objective confirmation that the true illness was present, and was not related to alternate rheumatologic diagnoses.”

They also noted the small number of patients in the subset analysis and pointed out there is no universal definition of reactive arthritis. “We elected to include enthesitis and inflammatory back pain in our case definition,” stated the researchers, who had no relevant conflicts. “Including only those with frank arthritis would obviously have resulted in a substantially lower estimate of the incidence.”

The study was supported by the Centers for Disease Control and Prevention and the Oregon Health and Science University General Clinical Research Center.

Campylobacter and Salmonella infections are the most common contributors to the incidence of reactive arthritis related to foodborne illness, judging from results of a population-based study in two states.

Dr. John M. Townes of Oregon Health and Science University, Portland, and associates conducted telephone interviews with residents of Minnesota and Oregon who had culture-confirmed Campylobacter, Escherichia coli O157, Salmonella, Shigella, and Yersinia infections reported to the Centers for Disease Control and Prevention's Foodborne Disease Active Surveillance Network between 2002 and 2004. Parents or legal guardians provided proxy interviews for those younger than 18 years of age. The researchers invited participants who reported new onset joint pain, joint swelling, back pain, heel pain, and morning stiffness lasting 3 days or more within 8 weeks of culture to complete a detailed questionnaire and physical examination.

Overall, 6,379 culture-confirmed infections were reported to FoodNet in Minnesota and Oregon between 2002 and 2004. The majority were caused by Campylobacter (53%) and Salmonella (30%), followed by E. coli O157 (9%), Shigella (7%), and Yersinia (1%). A total of 4,468 subjects (70%) were interviewed within 2 months of specimen collection. Of these, 575 (13%) reported having new onset of rheumatologic symptoms suggestive of reactive arthritis, which the investigators defined as a history or physical examination findings consistent with monoarthritis, oligoarthritis, dactylitis, enthesitis, or inflammatory back pain without other rheumatologic explanation. The adjusted odds ratio for having these symptoms was higher for subjects aged 18 years and older (OR 2.5), females (OR 1.5), and those who had signs of severe illness including fever, chills, headache, bloody stools, and persistent diarrhea at the time of screening (OR of these symptoms ranged from 1.6 to 2.8). Risk of having new onset of rheumatologic symptoms was not associated with antibiotic use or HLA-B27 (Ann. Rheum. Dis. 2008 Feb. 13 [doi:10.1136/ard.2007.083451

In a subset of 54 patients who met the criteria for the diagnosis of reactive arthritis based on history and physical examinations, Campylobacter was the most common organism of infection (33 cases), followed by Salmonella (17 cases), Shigella (2 cases), E. coli O157 (1 case), and Yersinia (1 case). Most cases were adults (96%) and female (67%). Enthesitis was the most frequent finding on physical exam (48 cases). Arthritis was seen in 10 cases. The incidence of reactive arthritis following culture-confirmed infections of Campylobacter, E. coli O157, Salmonella, Shigella, and Yersinia was estimated to be from 0.6 to 3.1 cases per 100,000 persons.

The researchers acknowledged certain limitations of the study, including the fact that “it is difficult to prove that the rheumatologic symptoms described by our subjects are truly attributable to the antecedent infections,” they reported. “However, by examining a subset of those with subjective symptoms, we were able to provide objective confirmation that the true illness was present, and was not related to alternate rheumatologic diagnoses.”

They also noted the small number of patients in the subset analysis and pointed out there is no universal definition of reactive arthritis. “We elected to include enthesitis and inflammatory back pain in our case definition,” stated the researchers, who had no relevant conflicts. “Including only those with frank arthritis would obviously have resulted in a substantially lower estimate of the incidence.”

The study was supported by the Centers for Disease Control and Prevention and the Oregon Health and Science University General Clinical Research Center.

Campylobacter and Salmonella infections are the most common contributors to the incidence of reactive arthritis related to foodborne illness, judging from results of a population-based study in two states.

Dr. John M. Townes of Oregon Health and Science University, Portland, and associates conducted telephone interviews with residents of Minnesota and Oregon who had culture-confirmed Campylobacter, Escherichia coli O157, Salmonella, Shigella, and Yersinia infections reported to the Centers for Disease Control and Prevention's Foodborne Disease Active Surveillance Network between 2002 and 2004. Parents or legal guardians provided proxy interviews for those younger than 18 years of age. The researchers invited participants who reported new onset joint pain, joint swelling, back pain, heel pain, and morning stiffness lasting 3 days or more within 8 weeks of culture to complete a detailed questionnaire and physical examination.

Overall, 6,379 culture-confirmed infections were reported to FoodNet in Minnesota and Oregon between 2002 and 2004. The majority were caused by Campylobacter (53%) and Salmonella (30%), followed by E. coli O157 (9%), Shigella (7%), and Yersinia (1%). A total of 4,468 subjects (70%) were interviewed within 2 months of specimen collection. Of these, 575 (13%) reported having new onset of rheumatologic symptoms suggestive of reactive arthritis, which the investigators defined as a history or physical examination findings consistent with monoarthritis, oligoarthritis, dactylitis, enthesitis, or inflammatory back pain without other rheumatologic explanation. The adjusted odds ratio for having these symptoms was higher for subjects aged 18 years and older (OR 2.5), females (OR 1.5), and those who had signs of severe illness including fever, chills, headache, bloody stools, and persistent diarrhea at the time of screening (OR of these symptoms ranged from 1.6 to 2.8). Risk of having new onset of rheumatologic symptoms was not associated with antibiotic use or HLA-B27 (Ann. Rheum. Dis. 2008 Feb. 13 [doi:10.1136/ard.2007.083451

In a subset of 54 patients who met the criteria for the diagnosis of reactive arthritis based on history and physical examinations, Campylobacter was the most common organism of infection (33 cases), followed by Salmonella (17 cases), Shigella (2 cases), E. coli O157 (1 case), and Yersinia (1 case). Most cases were adults (96%) and female (67%). Enthesitis was the most frequent finding on physical exam (48 cases). Arthritis was seen in 10 cases. The incidence of reactive arthritis following culture-confirmed infections of Campylobacter, E. coli O157, Salmonella, Shigella, and Yersinia was estimated to be from 0.6 to 3.1 cases per 100,000 persons.

The researchers acknowledged certain limitations of the study, including the fact that “it is difficult to prove that the rheumatologic symptoms described by our subjects are truly attributable to the antecedent infections,” they reported. “However, by examining a subset of those with subjective symptoms, we were able to provide objective confirmation that the true illness was present, and was not related to alternate rheumatologic diagnoses.”

They also noted the small number of patients in the subset analysis and pointed out there is no universal definition of reactive arthritis. “We elected to include enthesitis and inflammatory back pain in our case definition,” stated the researchers, who had no relevant conflicts. “Including only those with frank arthritis would obviously have resulted in a substantially lower estimate of the incidence.”

The study was supported by the Centers for Disease Control and Prevention and the Oregon Health and Science University General Clinical Research Center.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine. It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter this year while the adult formulation will be available in the fourth quarter.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine. It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter this year while the adult formulation will be available in the fourth quarter.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine. It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter this year while the adult formulation will be available in the fourth quarter.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

Year after year West Virginia ranks near the bottom, compared with other states in surveys of cardiovascular health and healthy lifestyle.

In 1995, the age-adjusted rate of heart disease was 328/100,000, which is 21% higher than the national average and 49th in the nation. Results from the 1997 Centers for Disease Control and Prevention Behavioral Risk Factor Survey revealed that West Virginia had the highest rate of obesity, the third highest rate of self-reported hypertension, and the fifth highest rate of smoking in the nation.

But today, a prevention effort known as the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project aims to reverse those trends. First launched in three West Virginia counties in 1998, the project offers free comprehensive cardiovascular risk screening to fifth graders in each of the state's 55 counties, who number about 20,000 each year.

The screenings—which are conducted at elementary and middle schools, and require active consent—include measurements of height, weight, and blood pressure; evaluation of the neck for acanthosis nigricans, and a fasting lipid profile.

In addition, parents of the children receive a voucher to have their own fasting lipid profile performed at a local laboratory.

Parents receive a letter in the mail detailing results of the screening test. “They range from 'your child's results are normal; continue providing a nutritious diet and physical activity opportunities,' to the other end of the spectrum,” said program founder and director Dr. William A. Neal of the section of pediatric cardiology at West Virginia University, Morgantown.

“Whenever results are significantly abnormal, we recommend that they consult their primary care provider. We do try to give them some specific advice. For example, if a child has a high cholesterol level, the recommendation is a low saturated fat diet and approximately 1 hour a day of physical activity. If the child has an LDL cholesterol of greater than 160 mg/dL, we recommend that they be evaluated in our children's lipid clinics. We conduct four of those each month around the state.”

Sometimes the screening identifies parents at risk for heart disease or diabetes or who have not been taking statins as prescribed. “We frequently hear, 'my doctor did want me to be on medicine but it made me achy and I didn't want to take it,' or something like that,” Dr. Neal said in an interview. “If a middle-aged adult has a cholesterol level of 300 mg/dL and should be on a statin but isn't, if they subsequently go on a statin, it reduces their chance of a sudden coronary event by about 40% in 1 week because of the suppression of the inflammatory reaction.”

In recent years, CARDIAC (www.cardiacwv.org

To date, CARDIAC has screened 3,539 kindergartners, 2,275 second graders, 46,212 fifth graders, and 1,328 ninth graders.

Results from the 2006–2007 school year demonstrated that 22% of kindergartners, 35% of second graders, 46% of fifth graders, and 48% of ninth graders were at or above the 85th percentile for body mass index. In addition, 17% of fifth graders and 23% of ninth graders had abnormal fasting lipid profiles.

Dr. Giovanni Piedimonte, chair of pediatrics at West Virginia University, Morgantown, credits the success of the project to the network of connections that Dr. Neal and his associates has built with school nurses, administrators, teachers, and clinicians in the state. This “allows them to access an incredible number of children with very high efficiency,” he commented in an interview.

Dr. Neal said that level of networking evolved because of CARDIAC's affiliation with the West Virginia Rural Health Education Partnership, a state-funded coalition of rural communities and higher education. As part of this program, all college students enrolled in health sciences programs in West Virginia must spend several months performing community service such as CARDIAC under the supervision of 640 field preceptors and 13 site coordinators.

“They become the people power that allows us to do this comprehensive screening,” he said, noting that many of the field preceptors are former students of his from WVU.

A steady funding stream keeps the program running. CARDIAC receives about $470,000 from the state of West Virginia each year, with the rest from federal government and private grants to meet its annual operating cost of $1.5 million. “We're fortunate that the state has recognized that this is important and funds us so we can continue to exist,” said Dr. Neal, who noted that BMI screening will be expanded next year to include seventh graders.

Another component of the CARDIAC project includes school-based interventions such as Healthy Hearts 4 Kids, a Web-based instructional module that was made available to West Virginia teachers in 2001. According to program materials, this intervention “encourages children to participate in physical activity regularly, eat properly, and avoid the use of tobacco products. It is designed to impact children's knowledge, attitudes, and behaviors related to these risk factors associated with cardiovascular health.”

To date, 17,516 students in West Virginia have participated in Healthy Hearts 4 Kids, according to Eloise Elliott, Ph.D., associate director of interventions for CARDIAC. Analysis of surveys conducted pre- and postintervention demonstrated that students improved in the content areas of heart knowledge, physical activity, nutrition, and tobacco use.

For example, when students from the 2005–2006 school year were asked “what is the minimum number of minutes each day experts recommend you should be physically active?” 28% provided the correct answer of 60 minutes before the intervention while 87% responded correctly thereafter.

Other evidence-based interventions are being implemented both in school and community settings, based on the needs of each respective community.

“We don't try to dictate what happens; we help communities accomplish what they think their priority should be in terms of an intervention,” Dr. Neal explained.

“This is not a West Virginia University project. This is a West Virginia project.”

Year after year West Virginia ranks near the bottom, compared with other states in surveys of cardiovascular health and healthy lifestyle.

In 1995, the age-adjusted rate of heart disease was 328/100,000, which is 21% higher than the national average and 49th in the nation. Results from the 1997 Centers for Disease Control and Prevention Behavioral Risk Factor Survey revealed that West Virginia had the highest rate of obesity, the third highest rate of self-reported hypertension, and the fifth highest rate of smoking in the nation.

But today, a prevention effort known as the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project aims to reverse those trends. First launched in three West Virginia counties in 1998, the project offers free comprehensive cardiovascular risk screening to fifth graders in each of the state's 55 counties, who number about 20,000 each year.

The screenings—which are conducted at elementary and middle schools, and require active consent—include measurements of height, weight, and blood pressure; evaluation of the neck for acanthosis nigricans, and a fasting lipid profile.

In addition, parents of the children receive a voucher to have their own fasting lipid profile performed at a local laboratory.

Parents receive a letter in the mail detailing results of the screening test. “They range from 'your child's results are normal; continue providing a nutritious diet and physical activity opportunities,' to the other end of the spectrum,” said program founder and director Dr. William A. Neal of the section of pediatric cardiology at West Virginia University, Morgantown.

“Whenever results are significantly abnormal, we recommend that they consult their primary care provider. We do try to give them some specific advice. For example, if a child has a high cholesterol level, the recommendation is a low saturated fat diet and approximately 1 hour a day of physical activity. If the child has an LDL cholesterol of greater than 160 mg/dL, we recommend that they be evaluated in our children's lipid clinics. We conduct four of those each month around the state.”

Sometimes the screening identifies parents at risk for heart disease or diabetes or who have not been taking statins as prescribed. “We frequently hear, 'my doctor did want me to be on medicine but it made me achy and I didn't want to take it,' or something like that,” Dr. Neal said in an interview. “If a middle-aged adult has a cholesterol level of 300 mg/dL and should be on a statin but isn't, if they subsequently go on a statin, it reduces their chance of a sudden coronary event by about 40% in 1 week because of the suppression of the inflammatory reaction.”

In recent years, CARDIAC (www.cardiacwv.org

To date, CARDIAC has screened 3,539 kindergartners, 2,275 second graders, 46,212 fifth graders, and 1,328 ninth graders.

Results from the 2006–2007 school year demonstrated that 22% of kindergartners, 35% of second graders, 46% of fifth graders, and 48% of ninth graders were at or above the 85th percentile for body mass index. In addition, 17% of fifth graders and 23% of ninth graders had abnormal fasting lipid profiles.

Dr. Giovanni Piedimonte, chair of pediatrics at West Virginia University, Morgantown, credits the success of the project to the network of connections that Dr. Neal and his associates has built with school nurses, administrators, teachers, and clinicians in the state. This “allows them to access an incredible number of children with very high efficiency,” he commented in an interview.

Dr. Neal said that level of networking evolved because of CARDIAC's affiliation with the West Virginia Rural Health Education Partnership, a state-funded coalition of rural communities and higher education. As part of this program, all college students enrolled in health sciences programs in West Virginia must spend several months performing community service such as CARDIAC under the supervision of 640 field preceptors and 13 site coordinators.

“They become the people power that allows us to do this comprehensive screening,” he said, noting that many of the field preceptors are former students of his from WVU.

A steady funding stream keeps the program running. CARDIAC receives about $470,000 from the state of West Virginia each year, with the rest from federal government and private grants to meet its annual operating cost of $1.5 million. “We're fortunate that the state has recognized that this is important and funds us so we can continue to exist,” said Dr. Neal, who noted that BMI screening will be expanded next year to include seventh graders.

Another component of the CARDIAC project includes school-based interventions such as Healthy Hearts 4 Kids, a Web-based instructional module that was made available to West Virginia teachers in 2001. According to program materials, this intervention “encourages children to participate in physical activity regularly, eat properly, and avoid the use of tobacco products. It is designed to impact children's knowledge, attitudes, and behaviors related to these risk factors associated with cardiovascular health.”

To date, 17,516 students in West Virginia have participated in Healthy Hearts 4 Kids, according to Eloise Elliott, Ph.D., associate director of interventions for CARDIAC. Analysis of surveys conducted pre- and postintervention demonstrated that students improved in the content areas of heart knowledge, physical activity, nutrition, and tobacco use.

For example, when students from the 2005–2006 school year were asked “what is the minimum number of minutes each day experts recommend you should be physically active?” 28% provided the correct answer of 60 minutes before the intervention while 87% responded correctly thereafter.

Other evidence-based interventions are being implemented both in school and community settings, based on the needs of each respective community.

“We don't try to dictate what happens; we help communities accomplish what they think their priority should be in terms of an intervention,” Dr. Neal explained.

“This is not a West Virginia University project. This is a West Virginia project.”

Year after year West Virginia ranks near the bottom, compared with other states in surveys of cardiovascular health and healthy lifestyle.

In 1995, the age-adjusted rate of heart disease was 328/100,000, which is 21% higher than the national average and 49th in the nation. Results from the 1997 Centers for Disease Control and Prevention Behavioral Risk Factor Survey revealed that West Virginia had the highest rate of obesity, the third highest rate of self-reported hypertension, and the fifth highest rate of smoking in the nation.

But today, a prevention effort known as the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project aims to reverse those trends. First launched in three West Virginia counties in 1998, the project offers free comprehensive cardiovascular risk screening to fifth graders in each of the state's 55 counties, who number about 20,000 each year.

The screenings—which are conducted at elementary and middle schools, and require active consent—include measurements of height, weight, and blood pressure; evaluation of the neck for acanthosis nigricans, and a fasting lipid profile.

In addition, parents of the children receive a voucher to have their own fasting lipid profile performed at a local laboratory.

Parents receive a letter in the mail detailing results of the screening test. “They range from 'your child's results are normal; continue providing a nutritious diet and physical activity opportunities,' to the other end of the spectrum,” said program founder and director Dr. William A. Neal of the section of pediatric cardiology at West Virginia University, Morgantown.

“Whenever results are significantly abnormal, we recommend that they consult their primary care provider. We do try to give them some specific advice. For example, if a child has a high cholesterol level, the recommendation is a low saturated fat diet and approximately 1 hour a day of physical activity. If the child has an LDL cholesterol of greater than 160 mg/dL, we recommend that they be evaluated in our children's lipid clinics. We conduct four of those each month around the state.”

Sometimes the screening identifies parents at risk for heart disease or diabetes or who have not been taking statins as prescribed. “We frequently hear, 'my doctor did want me to be on medicine but it made me achy and I didn't want to take it,' or something like that,” Dr. Neal said in an interview. “If a middle-aged adult has a cholesterol level of 300 mg/dL and should be on a statin but isn't, if they subsequently go on a statin, it reduces their chance of a sudden coronary event by about 40% in 1 week because of the suppression of the inflammatory reaction.”

In recent years, CARDIAC (www.cardiacwv.org

To date, CARDIAC has screened 3,539 kindergartners, 2,275 second graders, 46,212 fifth graders, and 1,328 ninth graders.

Results from the 2006–2007 school year demonstrated that 22% of kindergartners, 35% of second graders, 46% of fifth graders, and 48% of ninth graders were at or above the 85th percentile for body mass index. In addition, 17% of fifth graders and 23% of ninth graders had abnormal fasting lipid profiles.

Dr. Giovanni Piedimonte, chair of pediatrics at West Virginia University, Morgantown, credits the success of the project to the network of connections that Dr. Neal and his associates has built with school nurses, administrators, teachers, and clinicians in the state. This “allows them to access an incredible number of children with very high efficiency,” he commented in an interview.

Dr. Neal said that level of networking evolved because of CARDIAC's affiliation with the West Virginia Rural Health Education Partnership, a state-funded coalition of rural communities and higher education. As part of this program, all college students enrolled in health sciences programs in West Virginia must spend several months performing community service such as CARDIAC under the supervision of 640 field preceptors and 13 site coordinators.

“They become the people power that allows us to do this comprehensive screening,” he said, noting that many of the field preceptors are former students of his from WVU.

A steady funding stream keeps the program running. CARDIAC receives about $470,000 from the state of West Virginia each year, with the rest from federal government and private grants to meet its annual operating cost of $1.5 million. “We're fortunate that the state has recognized that this is important and funds us so we can continue to exist,” said Dr. Neal, who noted that BMI screening will be expanded next year to include seventh graders.

Another component of the CARDIAC project includes school-based interventions such as Healthy Hearts 4 Kids, a Web-based instructional module that was made available to West Virginia teachers in 2001. According to program materials, this intervention “encourages children to participate in physical activity regularly, eat properly, and avoid the use of tobacco products. It is designed to impact children's knowledge, attitudes, and behaviors related to these risk factors associated with cardiovascular health.”

To date, 17,516 students in West Virginia have participated in Healthy Hearts 4 Kids, according to Eloise Elliott, Ph.D., associate director of interventions for CARDIAC. Analysis of surveys conducted pre- and postintervention demonstrated that students improved in the content areas of heart knowledge, physical activity, nutrition, and tobacco use.

For example, when students from the 2005–2006 school year were asked “what is the minimum number of minutes each day experts recommend you should be physically active?” 28% provided the correct answer of 60 minutes before the intervention while 87% responded correctly thereafter.

Other evidence-based interventions are being implemented both in school and community settings, based on the needs of each respective community.

“We don't try to dictate what happens; we help communities accomplish what they think their priority should be in terms of an intervention,” Dr. Neal explained.

“This is not a West Virginia University project. This is a West Virginia project.”

CORONADO, CALIF. — One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems, because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60–69 doubles every 5 years to a prevalence of about 39% for people aged 90–95 (JAMA 2007;297:2391–404).

Dr. Acampora also recommended assessing the fall risk in the work-up of older patients with a suspected drinking problem, noting that gait directly affects long-term outcome. In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649–57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications. “One is that they take all of them—and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Confusion may be an early sign of an adverse drug event, he said; alcohol use can affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity.

Older problem drinkers usually need more medically focused intensive treatment for their addiction. DR. TREVISAN

CORONADO, CALIF. — One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems, because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60–69 doubles every 5 years to a prevalence of about 39% for people aged 90–95 (JAMA 2007;297:2391–404).

Dr. Acampora also recommended assessing the fall risk in the work-up of older patients with a suspected drinking problem, noting that gait directly affects long-term outcome. In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649–57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications. “One is that they take all of them—and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Confusion may be an early sign of an adverse drug event, he said; alcohol use can affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity.

Older problem drinkers usually need more medically focused intensive treatment for their addiction. DR. TREVISAN

CORONADO, CALIF. — One decisive factor that sets older adults who abuse alcohol apart from their younger counterparts is a generally lower level of tolerance for the substance.

“They may have problems with lower intake due to the increased sensitivity to the alcohol, and therefore have higher blood alcohol levels with less intake,” Dr. Louis A. Trevisan said at the annual meeting of the American Academy of Addiction Psychiatry.

According to the National Epidemiologic Survey on Alcohol and Related Conditions, a community survey conducted in 2001 and 2002 by the National Institute on Alcohol Abuse and Alcoholism, the prevalence of alcohol use disorder among people aged 65 years and older is 1.35%. Dr. Trevisan, a geriatric and addiction psychiatrist at Yale University, New Haven, Conn., said that elderly alcoholics fall into types: those who start drinking well before they reach age 50 (earlier elderly onset) and those who start drinking after age 50 (later elderly onset).

Earlier elderly onset alcoholics “make up the large majority of older problem drinkers,” he said. “They usually have chronic alcohol-related medical problems, a positive family history, serious psychiatric comorbidities.” In addition, he said, older problem drinkers usually are less socially adjusted, may have an intractable course and more legal problems, and usually need more medically focused intensive treatment for their addiction.

Later elderly onset alcoholics usually begin drinking after a stress-related event, such as death of a spouse, family member, or close friend, or the loss of a job or a home. “They're usually more emotionally stable, usually have a milder clinical picture, and in general they have greater life satisfaction,” Dr. Trevisan said.

They also tend to respond better to treatment, compared with earlier onset alcoholics.

Other risk factors associated with the development of addiction in late life include a personal history of alcohol abuse or use in the past, chronic pain, predisposition to depression or anxiety disorders, and loss of social support or retirement.

Dr. Gregory Acampora, a substance abuse fellow at the Yale/VA Alcohol Research Center, advised clinicians to assess the mental status of older patients with suspected alcohol problems, because the effects of alcohol only exacerbate underlying cognitive infirmities. This is important, because cognitive impairment is dose related acutely “and can cause persistent cognitive deficits.”

Dementia often is prevalent in this patient population and affects agnosia, aphasia, apraxia, or a disturbance in executive functioning. The 1% prevalence of dementia for people aged 60–69 doubles every 5 years to a prevalence of about 39% for people aged 90–95 (JAMA 2007;297:2391–404).

Dr. Acampora also recommended assessing the fall risk in the work-up of older patients with a suspected drinking problem, noting that gait directly affects long-term outcome. In addition, research has demonstrated that a history of problem drinking is associated with a significantly greater risk of falls (J. Am. Geriatr. Soc. 2006;54:1649–57).

He went on to note that medication interaction “has to be considered” in the work-up of older adults with a suspected drinking problem, and that two “misadventures” can occur with patients who take several prescription medications. “One is that they take all of them—and for each drug there is an increased risk of a drug-drug interaction,” Dr. Acampora said. “The other is that they don't take the drug. The disease state may worsen, and a clinician may end up trying to adjust against his belief that a patient is taking the medication” when in fact he or she is not.

Confusion may be an early sign of an adverse drug event, he said; alcohol use can affect the pharmacodynamics and pharmacokinetics of medications and add potential for toxicity.

Older problem drinkers usually need more medically focused intensive treatment for their addiction. DR. TREVISAN

SAN DIEGO — When it comes to follow-up surveillance of melanoma patients, history and physical examination remain the cornerstone of good care, with little solid evidence to support anything else.

“The literature on this aspect of melanoma management is incomplete, mainly because there are very few prospective studies,” Dr. Peter R. Shumaker said at a melanoma update sponsored by the Scripps Clinic. He discussed several goals for postoperative follow-up:

▸ Earliest possible detection of treatable recurrence. About one-quarter of patients with local disease and 60%–70% of patients with in-transit [and] nodal disease will develop recurrence, said Dr. Shumaker, clinical fellow in procedural dermatology at the Scripps Clinic in La Jolla, Calif.

One study that reviewed the rate of first recurrence after treatment for malignant melanoma in 250 Australian patients found that 52% of recurrences were in the regional lymph nodes, 17% were local, 8% were in-transit, and 23% were visceral (Plast. Reconstr. Surg. 1993;91:94–8). Most recurrences occur within the first couple of years, he said, adding that patients are never considered unequivocally cured.

▸ Detection of other primary skin cancers. “These patients are at high risk for a second primary melanoma,” Dr. Shumaker warned.

▸ Patient education, emotional support, and reassurance. Most data show that at least half of recurrences are found by the patients themselves, despite being in a structured follow-up program. “These follow-ups, [provide] an opportunity to inspect and palpate lesions [and] educate patients.”

▸ Quality assurance. By this Dr. Shumaker meant the collection of data to improve future treatment and surveillance strategies, such as blood tests and imaging techniques. Chest x-rays and blood tests are often used in the routine follow-up of melanoma patients, “but offer little benefit in terms of cost effectiveness,” he said. They generally provide low sensitivity and a high rate of false positives. “Even if occult metastases are found, there is no clear evidence that there is an overall survival benefit with these tests. Even if abnormal, blood tests are rarely the sole indicator of recurrent disease.”

Dr. Shumaker considers 18fluorodeoxy-glucose positron emission tomography (FDG-PET) combined with computed tomography a “promising” whole-body imaging technique for follow-up in high-risk patients or in symptomatic patients at any stage. The technique can detect subclinical metastases because of their elevated metabolic activity but has limited sensitivity in tumors 5 mm or smaller.

Ultrasound seems “more sensitive than physical exam in detecting tumor recurrence in in-transit routes and regional nodal basins. There is an increased likelihood of survival benefit from asymptomatic detection in these areas.” He noted that ultrasound can be combined with fine-needle aspiration to diagnose recurrent or metastatic disease, but there appears to be no role for abdominal ultrasound in routine follow-up.

At Scripps, Dr. Shumaker and his associates perform a comprehensive history and physical exam in melanoma patients every 3 months for 3 years, then every 6 months for life. “This includes baseline and an annual chest x-ray and lab tests,” he said.

They refer patients with high-risk, thick melanomas to their colleagues in hematology/oncology. “We have a very low threshold for obtaining additional studies in symptomatic patients. Many patients with high-risk melanoma have a baseline FDG-PET/CT scan. You could consider that for your high-risk patients in follow-up.”

Most data show that at least half of recurrencesare found by the patients themselves. DR. SHUMAKER

SAN DIEGO — When it comes to follow-up surveillance of melanoma patients, history and physical examination remain the cornerstone of good care, with little solid evidence to support anything else.

“The literature on this aspect of melanoma management is incomplete, mainly because there are very few prospective studies,” Dr. Peter R. Shumaker said at a melanoma update sponsored by the Scripps Clinic. He discussed several goals for postoperative follow-up:

▸ Earliest possible detection of treatable recurrence. About one-quarter of patients with local disease and 60%–70% of patients with in-transit [and] nodal disease will develop recurrence, said Dr. Shumaker, clinical fellow in procedural dermatology at the Scripps Clinic in La Jolla, Calif.

One study that reviewed the rate of first recurrence after treatment for malignant melanoma in 250 Australian patients found that 52% of recurrences were in the regional lymph nodes, 17% were local, 8% were in-transit, and 23% were visceral (Plast. Reconstr. Surg. 1993;91:94–8). Most recurrences occur within the first couple of years, he said, adding that patients are never considered unequivocally cured.

▸ Detection of other primary skin cancers. “These patients are at high risk for a second primary melanoma,” Dr. Shumaker warned.

▸ Patient education, emotional support, and reassurance. Most data show that at least half of recurrences are found by the patients themselves, despite being in a structured follow-up program. “These follow-ups, [provide] an opportunity to inspect and palpate lesions [and] educate patients.”

▸ Quality assurance. By this Dr. Shumaker meant the collection of data to improve future treatment and surveillance strategies, such as blood tests and imaging techniques. Chest x-rays and blood tests are often used in the routine follow-up of melanoma patients, “but offer little benefit in terms of cost effectiveness,” he said. They generally provide low sensitivity and a high rate of false positives. “Even if occult metastases are found, there is no clear evidence that there is an overall survival benefit with these tests. Even if abnormal, blood tests are rarely the sole indicator of recurrent disease.”

Dr. Shumaker considers 18fluorodeoxy-glucose positron emission tomography (FDG-PET) combined with computed tomography a “promising” whole-body imaging technique for follow-up in high-risk patients or in symptomatic patients at any stage. The technique can detect subclinical metastases because of their elevated metabolic activity but has limited sensitivity in tumors 5 mm or smaller.

Ultrasound seems “more sensitive than physical exam in detecting tumor recurrence in in-transit routes and regional nodal basins. There is an increased likelihood of survival benefit from asymptomatic detection in these areas.” He noted that ultrasound can be combined with fine-needle aspiration to diagnose recurrent or metastatic disease, but there appears to be no role for abdominal ultrasound in routine follow-up.

At Scripps, Dr. Shumaker and his associates perform a comprehensive history and physical exam in melanoma patients every 3 months for 3 years, then every 6 months for life. “This includes baseline and an annual chest x-ray and lab tests,” he said.

They refer patients with high-risk, thick melanomas to their colleagues in hematology/oncology. “We have a very low threshold for obtaining additional studies in symptomatic patients. Many patients with high-risk melanoma have a baseline FDG-PET/CT scan. You could consider that for your high-risk patients in follow-up.”

Most data show that at least half of recurrencesare found by the patients themselves. DR. SHUMAKER

SAN DIEGO — When it comes to follow-up surveillance of melanoma patients, history and physical examination remain the cornerstone of good care, with little solid evidence to support anything else.

“The literature on this aspect of melanoma management is incomplete, mainly because there are very few prospective studies,” Dr. Peter R. Shumaker said at a melanoma update sponsored by the Scripps Clinic. He discussed several goals for postoperative follow-up:

▸ Earliest possible detection of treatable recurrence. About one-quarter of patients with local disease and 60%–70% of patients with in-transit [and] nodal disease will develop recurrence, said Dr. Shumaker, clinical fellow in procedural dermatology at the Scripps Clinic in La Jolla, Calif.

One study that reviewed the rate of first recurrence after treatment for malignant melanoma in 250 Australian patients found that 52% of recurrences were in the regional lymph nodes, 17% were local, 8% were in-transit, and 23% were visceral (Plast. Reconstr. Surg. 1993;91:94–8). Most recurrences occur within the first couple of years, he said, adding that patients are never considered unequivocally cured.

▸ Detection of other primary skin cancers. “These patients are at high risk for a second primary melanoma,” Dr. Shumaker warned.

▸ Patient education, emotional support, and reassurance. Most data show that at least half of recurrences are found by the patients themselves, despite being in a structured follow-up program. “These follow-ups, [provide] an opportunity to inspect and palpate lesions [and] educate patients.”

▸ Quality assurance. By this Dr. Shumaker meant the collection of data to improve future treatment and surveillance strategies, such as blood tests and imaging techniques. Chest x-rays and blood tests are often used in the routine follow-up of melanoma patients, “but offer little benefit in terms of cost effectiveness,” he said. They generally provide low sensitivity and a high rate of false positives. “Even if occult metastases are found, there is no clear evidence that there is an overall survival benefit with these tests. Even if abnormal, blood tests are rarely the sole indicator of recurrent disease.”

Dr. Shumaker considers 18fluorodeoxy-glucose positron emission tomography (FDG-PET) combined with computed tomography a “promising” whole-body imaging technique for follow-up in high-risk patients or in symptomatic patients at any stage. The technique can detect subclinical metastases because of their elevated metabolic activity but has limited sensitivity in tumors 5 mm or smaller.

Ultrasound seems “more sensitive than physical exam in detecting tumor recurrence in in-transit routes and regional nodal basins. There is an increased likelihood of survival benefit from asymptomatic detection in these areas.” He noted that ultrasound can be combined with fine-needle aspiration to diagnose recurrent or metastatic disease, but there appears to be no role for abdominal ultrasound in routine follow-up.

At Scripps, Dr. Shumaker and his associates perform a comprehensive history and physical exam in melanoma patients every 3 months for 3 years, then every 6 months for life. “This includes baseline and an annual chest x-ray and lab tests,” he said.

They refer patients with high-risk, thick melanomas to their colleagues in hematology/oncology. “We have a very low threshold for obtaining additional studies in symptomatic patients. Many patients with high-risk melanoma have a baseline FDG-PET/CT scan. You could consider that for your high-risk patients in follow-up.”

Most data show that at least half of recurrencesare found by the patients themselves. DR. SHUMAKER

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008 while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008 while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

A production delay has caused Merck & Co. to temporarily stop accepting orders for the pediatric and adult vial formulations of Vaqta, the hepatitis A vaccine.

It is estimated that the pediatric formulation of Vaqta will be available in the early third quarter of 2008 while the adult formulation will be available in the fourth quarter of 2008.

In the meantime, the Centers for Disease Control and Prevention reported, the pediatric and adult formulations of GlaxoSmithKline's hepatitis A vaccine Havrix, and its adult hepatitis A/hepatitis B combination vaccine (Twinrix) “are currently in good supply to meet demand.”

GlaxoSmithKline plans to increase production of both vaccines to help ensure uninterrupted supply for the United States market.

There has been no change in the routine recommendations for hepatitis A vaccinations, the CDC said.

CORONADO, CALIF. – Treatment and continuing care are two key components to a chronic care approach to effective recovery for patients with a substance abuse problem.

But in a correctional setting, that basic model faces several challenges and is sometimes impossible to employ, Dr. Jack Kuo said at the annual meeting of the American Academy of Addiction Psychiatry.

Frequent lockdowns, lack of communication between mental health and substance abuse staff, and access to drugs by inmates are just a few obstacles he faces as a staff psychiatrist for the California Department of Corrections and Rehabilitation.

“Many people think that prisoners with substance abuse problems are abstinent because they are in prison,” he said. “Unfortunately, that's not always the case. They have access through various types of smugglings, sometimes through visitors to the inmates, sometimes through guards, sometimes through medical personnel. You do have a number of illegal drugs that make their way into the system.”

Abuse of prescription medications is common, he said, and inmates “will manufacture complaints to get their hands on these products.” A popular drug of abuse is Wellbutrin, “which a lot of them will crush and snort as a cheap stimulant. A lot of them will also use Seroquel or other types of sedating medications.”

Interventions that have been demonstrated in research studies to be effective for drug-abusing offenders include residential substance abuse treatment, cognitive-behavioral therapy, contingency management, and medications. However, treatment must last an average of 90 days to produce stable behavior change, Dr. Kuo said. That's difficult to achieve in a state prison system like California's, where lockdowns because of infighting or gang violence shut down prison yards for months at a time and medications such as methadone, naltrexone, and buprenorphine cannot be used.

In addition, some correctional officers may frown upon efforts to rehabilitate inmates with a history of substance abuse. “They figure, 'hey these people did something that's illegal. That's why they're locked up. Why should they get treatment?' Overcoming those types of attitudes can be fundamental to providing treatment.”

The California Department of Corrections and Rehabilitation provides services to 9,200 inmates in 22 prisons. All programs use the therapeutic community model and are operated by private companies. A report issued in February 2007 by the California Office of Inspector General found that despite an annual cost of $36 million, the state's in-prison substance abuse treatment programs have little or no effect on recidivism.

To improve the current system, Dr. Kuo recommends integrated public health and safety strategies that involve research-based treatment under close supervision, the opportunity to avoid incarceration or a criminal record when possible, and consequences for noncompliance. Treatment that emphasizes contingency management holds the most promise, he said.

“Treatment does not need to be voluntary to be effective,” added Dr. Kuo, who is also a psychiatrist with Promises Treatment Centers in Malibu, Calif. “Strong motivation can facilitate the treatment process. Sanctions or incentives related to family, employment, or the criminal justice system can significantly increase treatment entry and retention rates and the success of drug treatment interventions. It is important to use rewards and sanctions to encourage prosocial behavior and treatment progress.”

Research has shown that using rewards to recognize progress is an effective way to change behavior. “Rewards can take many forms, including certificates of achievement or verbal praise from an authority figure such as a judge,” he said. “Establishing an attitude of 'catching people doing things right' creates a positive environment for fostering and maintaining behavior change.”

CORONADO, CALIF. – Treatment and continuing care are two key components to a chronic care approach to effective recovery for patients with a substance abuse problem.

But in a correctional setting, that basic model faces several challenges and is sometimes impossible to employ, Dr. Jack Kuo said at the annual meeting of the American Academy of Addiction Psychiatry.

Frequent lockdowns, lack of communication between mental health and substance abuse staff, and access to drugs by inmates are just a few obstacles he faces as a staff psychiatrist for the California Department of Corrections and Rehabilitation.

“Many people think that prisoners with substance abuse problems are abstinent because they are in prison,” he said. “Unfortunately, that's not always the case. They have access through various types of smugglings, sometimes through visitors to the inmates, sometimes through guards, sometimes through medical personnel. You do have a number of illegal drugs that make their way into the system.”

Abuse of prescription medications is common, he said, and inmates “will manufacture complaints to get their hands on these products.” A popular drug of abuse is Wellbutrin, “which a lot of them will crush and snort as a cheap stimulant. A lot of them will also use Seroquel or other types of sedating medications.”

Interventions that have been demonstrated in research studies to be effective for drug-abusing offenders include residential substance abuse treatment, cognitive-behavioral therapy, contingency management, and medications. However, treatment must last an average of 90 days to produce stable behavior change, Dr. Kuo said. That's difficult to achieve in a state prison system like California's, where lockdowns because of infighting or gang violence shut down prison yards for months at a time and medications such as methadone, naltrexone, and buprenorphine cannot be used.

In addition, some correctional officers may frown upon efforts to rehabilitate inmates with a history of substance abuse. “They figure, 'hey these people did something that's illegal. That's why they're locked up. Why should they get treatment?' Overcoming those types of attitudes can be fundamental to providing treatment.”

The California Department of Corrections and Rehabilitation provides services to 9,200 inmates in 22 prisons. All programs use the therapeutic community model and are operated by private companies. A report issued in February 2007 by the California Office of Inspector General found that despite an annual cost of $36 million, the state's in-prison substance abuse treatment programs have little or no effect on recidivism.

To improve the current system, Dr. Kuo recommends integrated public health and safety strategies that involve research-based treatment under close supervision, the opportunity to avoid incarceration or a criminal record when possible, and consequences for noncompliance. Treatment that emphasizes contingency management holds the most promise, he said.

“Treatment does not need to be voluntary to be effective,” added Dr. Kuo, who is also a psychiatrist with Promises Treatment Centers in Malibu, Calif. “Strong motivation can facilitate the treatment process. Sanctions or incentives related to family, employment, or the criminal justice system can significantly increase treatment entry and retention rates and the success of drug treatment interventions. It is important to use rewards and sanctions to encourage prosocial behavior and treatment progress.”

Research has shown that using rewards to recognize progress is an effective way to change behavior. “Rewards can take many forms, including certificates of achievement or verbal praise from an authority figure such as a judge,” he said. “Establishing an attitude of 'catching people doing things right' creates a positive environment for fostering and maintaining behavior change.”

CORONADO, CALIF. – Treatment and continuing care are two key components to a chronic care approach to effective recovery for patients with a substance abuse problem.

But in a correctional setting, that basic model faces several challenges and is sometimes impossible to employ, Dr. Jack Kuo said at the annual meeting of the American Academy of Addiction Psychiatry.

Frequent lockdowns, lack of communication between mental health and substance abuse staff, and access to drugs by inmates are just a few obstacles he faces as a staff psychiatrist for the California Department of Corrections and Rehabilitation.

“Many people think that prisoners with substance abuse problems are abstinent because they are in prison,” he said. “Unfortunately, that's not always the case. They have access through various types of smugglings, sometimes through visitors to the inmates, sometimes through guards, sometimes through medical personnel. You do have a number of illegal drugs that make their way into the system.”

Abuse of prescription medications is common, he said, and inmates “will manufacture complaints to get their hands on these products.” A popular drug of abuse is Wellbutrin, “which a lot of them will crush and snort as a cheap stimulant. A lot of them will also use Seroquel or other types of sedating medications.”

Interventions that have been demonstrated in research studies to be effective for drug-abusing offenders include residential substance abuse treatment, cognitive-behavioral therapy, contingency management, and medications. However, treatment must last an average of 90 days to produce stable behavior change, Dr. Kuo said. That's difficult to achieve in a state prison system like California's, where lockdowns because of infighting or gang violence shut down prison yards for months at a time and medications such as methadone, naltrexone, and buprenorphine cannot be used.

In addition, some correctional officers may frown upon efforts to rehabilitate inmates with a history of substance abuse. “They figure, 'hey these people did something that's illegal. That's why they're locked up. Why should they get treatment?' Overcoming those types of attitudes can be fundamental to providing treatment.”

The California Department of Corrections and Rehabilitation provides services to 9,200 inmates in 22 prisons. All programs use the therapeutic community model and are operated by private companies. A report issued in February 2007 by the California Office of Inspector General found that despite an annual cost of $36 million, the state's in-prison substance abuse treatment programs have little or no effect on recidivism.

To improve the current system, Dr. Kuo recommends integrated public health and safety strategies that involve research-based treatment under close supervision, the opportunity to avoid incarceration or a criminal record when possible, and consequences for noncompliance. Treatment that emphasizes contingency management holds the most promise, he said.

“Treatment does not need to be voluntary to be effective,” added Dr. Kuo, who is also a psychiatrist with Promises Treatment Centers in Malibu, Calif. “Strong motivation can facilitate the treatment process. Sanctions or incentives related to family, employment, or the criminal justice system can significantly increase treatment entry and retention rates and the success of drug treatment interventions. It is important to use rewards and sanctions to encourage prosocial behavior and treatment progress.”

Research has shown that using rewards to recognize progress is an effective way to change behavior. “Rewards can take many forms, including certificates of achievement or verbal praise from an authority figure such as a judge,” he said. “Establishing an attitude of 'catching people doing things right' creates a positive environment for fostering and maintaining behavior change.”