Doug Brunk

LAS VEGAS — When rosacea overlaps with another skin disease, certain topical treatments are better than others, Guy F. Webster, M.D., said at the Fall Clinical Dermatology Conference.

“I'm finding there are subsets of topical treatments that are good for subsets of disease,” said Dr. Webster of the department of dermatology at Jefferson Medical College, Philadelphia. “There's a new 1% metronidazole out that's a little stronger, and the topical immunomodulators are useful when someone has rosacea plus seborrheic dermatitis, or [for] someone with atopic dermatitis plus seborrheic dermatitis.”

Another subset of rosacea patients he described are those who had severe acne as teenagers. “They've often been through Accutane [isotretinoin], and then they're in their mid to late 20s, and they start getting rosacea,” he explained at the conference, sponsored by the Center for Bio-Medical Communication Inc. “With them I find the benzoyl peroxide/clindamycin mixtures are often very effective.”

Azelaic acid and sodium sulfacetamide/sulfur have a role in rosacea treatment, he noted, but sodium sulfacetamide/sulfur “isn't quite as strong as the other topicals.”

He added that evidence to support the use of tretinoin for rosacea is in the realm of speculation. Studies of fair-skinned people who live in areas of high sun exposure make him wonder if what the investigators really observed were improvements in sun damage and not rosacea. “But it's clear that if you're patient enough in a person like that, you can get some aspects of their rosacea to improve with tretinoin,” Dr. Webster said.

He credited the efficacy of metronidazole 1% to not only a boost in drug concentration from the 0.75% form, but to the fact that the agent is contained in a modern vehicle.

“Many of the drugs we have are [contained in] old-fashioned vehicles that were formulated 15–20 years ago, even though maybe they've only been approved for 5–10 years,” Dr. Webster said at the conference.

“A lot has gone on in vehicle technology since then. This is a new, modern vehicle, and it optimizes the health of the skin.”

As for oral rosacea therapy, effective options include tetracycline, doxycycline, and minocycline, which are antibacterial and anti-inflammatory.

Cipro (ciprofloxacin) and Bactrim (trimethoprim/sulfamethoxazole) both work, “but there's a worry with giving people long-term antibiotic treatment for a disease that is chronic,” he noted.

“You worry about generating resistance to bacteria and making other infections harder to treat. We should get patients as clear as we can with an oral antibiotic and then try to get them onto something that's either nonantibiotic or topical.”

Dr. Webster said that isotretinoin is not as “magic” for rosacea as it is for acne. “It's better for nodules than a lot of other drugs for rosacea, but it doesn't work as quickly as you would expect. I'd save it for a situation where all else fails.”

Other drugs that he finds “occasionally effective” include β-blockers and selective serotonin reuptake inhibitors. β-Blockers “will sometime make a patient who is 'flushy' and 'blushy' and a little bit agitated have less flushing and blushing, but it's not as magical as you'd hope,” he remarked.

“Sometimes patients who are anxious in general benefit from an SSRI. They're a fairly big part of my practice. I use them for acne patients and agitated rosacea folks, and eczema patients.”

One promising new treatment for rosacea is topical dapsone gel. “I think it will probably be better for rosacea than it will be for acne, but there's a problem,” he said.

“The [Food and Drug Administration] is insistent on having blood tests because they're worried about the risk of hemolysis. I'm wondering at this point if we'll ever see the product. But if it comes out I think it will be useful effects for rosacea because of its anti-inflammatory activity.”

Another new therapy is anti-inflammatory-dose doxycycline. Doxycycline can be given in a dose so low “that it doesn't change the oral flora or GI flora, but it still has a lot of the anti-inflammatory activity,” Dr. Webster said.

Even more promising in the future, he added, is a drug called incyclinide, “which is a chemically modified doxycycline that has no antibiotic activity but whopping anti-inflammatory activity. This drug is real promising.”

LAS VEGAS — When rosacea overlaps with another skin disease, certain topical treatments are better than others, Guy F. Webster, M.D., said at the Fall Clinical Dermatology Conference.

“I'm finding there are subsets of topical treatments that are good for subsets of disease,” said Dr. Webster of the department of dermatology at Jefferson Medical College, Philadelphia. “There's a new 1% metronidazole out that's a little stronger, and the topical immunomodulators are useful when someone has rosacea plus seborrheic dermatitis, or [for] someone with atopic dermatitis plus seborrheic dermatitis.”

Another subset of rosacea patients he described are those who had severe acne as teenagers. “They've often been through Accutane [isotretinoin], and then they're in their mid to late 20s, and they start getting rosacea,” he explained at the conference, sponsored by the Center for Bio-Medical Communication Inc. “With them I find the benzoyl peroxide/clindamycin mixtures are often very effective.”

Azelaic acid and sodium sulfacetamide/sulfur have a role in rosacea treatment, he noted, but sodium sulfacetamide/sulfur “isn't quite as strong as the other topicals.”

He added that evidence to support the use of tretinoin for rosacea is in the realm of speculation. Studies of fair-skinned people who live in areas of high sun exposure make him wonder if what the investigators really observed were improvements in sun damage and not rosacea. “But it's clear that if you're patient enough in a person like that, you can get some aspects of their rosacea to improve with tretinoin,” Dr. Webster said.

He credited the efficacy of metronidazole 1% to not only a boost in drug concentration from the 0.75% form, but to the fact that the agent is contained in a modern vehicle.

“Many of the drugs we have are [contained in] old-fashioned vehicles that were formulated 15–20 years ago, even though maybe they've only been approved for 5–10 years,” Dr. Webster said at the conference.

“A lot has gone on in vehicle technology since then. This is a new, modern vehicle, and it optimizes the health of the skin.”

As for oral rosacea therapy, effective options include tetracycline, doxycycline, and minocycline, which are antibacterial and anti-inflammatory.

Cipro (ciprofloxacin) and Bactrim (trimethoprim/sulfamethoxazole) both work, “but there's a worry with giving people long-term antibiotic treatment for a disease that is chronic,” he noted.

“You worry about generating resistance to bacteria and making other infections harder to treat. We should get patients as clear as we can with an oral antibiotic and then try to get them onto something that's either nonantibiotic or topical.”

Dr. Webster said that isotretinoin is not as “magic” for rosacea as it is for acne. “It's better for nodules than a lot of other drugs for rosacea, but it doesn't work as quickly as you would expect. I'd save it for a situation where all else fails.”

Other drugs that he finds “occasionally effective” include β-blockers and selective serotonin reuptake inhibitors. β-Blockers “will sometime make a patient who is 'flushy' and 'blushy' and a little bit agitated have less flushing and blushing, but it's not as magical as you'd hope,” he remarked.

“Sometimes patients who are anxious in general benefit from an SSRI. They're a fairly big part of my practice. I use them for acne patients and agitated rosacea folks, and eczema patients.”

One promising new treatment for rosacea is topical dapsone gel. “I think it will probably be better for rosacea than it will be for acne, but there's a problem,” he said.

“The [Food and Drug Administration] is insistent on having blood tests because they're worried about the risk of hemolysis. I'm wondering at this point if we'll ever see the product. But if it comes out I think it will be useful effects for rosacea because of its anti-inflammatory activity.”

Another new therapy is anti-inflammatory-dose doxycycline. Doxycycline can be given in a dose so low “that it doesn't change the oral flora or GI flora, but it still has a lot of the anti-inflammatory activity,” Dr. Webster said.

Even more promising in the future, he added, is a drug called incyclinide, “which is a chemically modified doxycycline that has no antibiotic activity but whopping anti-inflammatory activity. This drug is real promising.”

LAS VEGAS — When rosacea overlaps with another skin disease, certain topical treatments are better than others, Guy F. Webster, M.D., said at the Fall Clinical Dermatology Conference.

“I'm finding there are subsets of topical treatments that are good for subsets of disease,” said Dr. Webster of the department of dermatology at Jefferson Medical College, Philadelphia. “There's a new 1% metronidazole out that's a little stronger, and the topical immunomodulators are useful when someone has rosacea plus seborrheic dermatitis, or [for] someone with atopic dermatitis plus seborrheic dermatitis.”

Another subset of rosacea patients he described are those who had severe acne as teenagers. “They've often been through Accutane [isotretinoin], and then they're in their mid to late 20s, and they start getting rosacea,” he explained at the conference, sponsored by the Center for Bio-Medical Communication Inc. “With them I find the benzoyl peroxide/clindamycin mixtures are often very effective.”

Azelaic acid and sodium sulfacetamide/sulfur have a role in rosacea treatment, he noted, but sodium sulfacetamide/sulfur “isn't quite as strong as the other topicals.”

He added that evidence to support the use of tretinoin for rosacea is in the realm of speculation. Studies of fair-skinned people who live in areas of high sun exposure make him wonder if what the investigators really observed were improvements in sun damage and not rosacea. “But it's clear that if you're patient enough in a person like that, you can get some aspects of their rosacea to improve with tretinoin,” Dr. Webster said.

He credited the efficacy of metronidazole 1% to not only a boost in drug concentration from the 0.75% form, but to the fact that the agent is contained in a modern vehicle.

“Many of the drugs we have are [contained in] old-fashioned vehicles that were formulated 15–20 years ago, even though maybe they've only been approved for 5–10 years,” Dr. Webster said at the conference.

“A lot has gone on in vehicle technology since then. This is a new, modern vehicle, and it optimizes the health of the skin.”

As for oral rosacea therapy, effective options include tetracycline, doxycycline, and minocycline, which are antibacterial and anti-inflammatory.

Cipro (ciprofloxacin) and Bactrim (trimethoprim/sulfamethoxazole) both work, “but there's a worry with giving people long-term antibiotic treatment for a disease that is chronic,” he noted.

“You worry about generating resistance to bacteria and making other infections harder to treat. We should get patients as clear as we can with an oral antibiotic and then try to get them onto something that's either nonantibiotic or topical.”

Dr. Webster said that isotretinoin is not as “magic” for rosacea as it is for acne. “It's better for nodules than a lot of other drugs for rosacea, but it doesn't work as quickly as you would expect. I'd save it for a situation where all else fails.”

Other drugs that he finds “occasionally effective” include β-blockers and selective serotonin reuptake inhibitors. β-Blockers “will sometime make a patient who is 'flushy' and 'blushy' and a little bit agitated have less flushing and blushing, but it's not as magical as you'd hope,” he remarked.

“Sometimes patients who are anxious in general benefit from an SSRI. They're a fairly big part of my practice. I use them for acne patients and agitated rosacea folks, and eczema patients.”

One promising new treatment for rosacea is topical dapsone gel. “I think it will probably be better for rosacea than it will be for acne, but there's a problem,” he said.

“The [Food and Drug Administration] is insistent on having blood tests because they're worried about the risk of hemolysis. I'm wondering at this point if we'll ever see the product. But if it comes out I think it will be useful effects for rosacea because of its anti-inflammatory activity.”

Another new therapy is anti-inflammatory-dose doxycycline. Doxycycline can be given in a dose so low “that it doesn't change the oral flora or GI flora, but it still has a lot of the anti-inflammatory activity,” Dr. Webster said.

Even more promising in the future, he added, is a drug called incyclinide, “which is a chemically modified doxycycline that has no antibiotic activity but whopping anti-inflammatory activity. This drug is real promising.”

LAS VEGAS — If you're stumped about how to manage your patients with severe atopic dermatitis, Amy S. Paller, M.D., offered clear-cut advice at the Fall Clinical Dermatology Conference.

“It's important to see if there's a problem with what they're doing on a basic level,” said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago. “How often are they bathing? Once a day or at least every other day? Are they following that with a good thick moisturizer that can improve that underlying skin barrier? What about harsh agents? Are they avoiding bubble baths and harsh soaps? Is there a benefit of a soft water system?”

She offered the following tips for managing these patients:

▸ Consider wrap management. After patients bathe and apply topical medication or moisturizer to their skin, have them put on damp, long underwear-type cotton pajamas and socks. Top this with a dry layer of pajamas and a dry layer of socks. This strategy “decreases the pruritus and discomfort and helps kids fall asleep,” said Dr. Paller, who is also a professor of pediatrics at the university. “In severely affected infants it's been a wonderful addition without doing anything else that might increase the strength of medication that you're using. You can modify this as well for hand dermatitis by putting on damp gloves topped with dry gloves.”

She cautioned that wet wraps “can theoretically increase the absorption of topically applied medications. That's why in my practice I primarily use this directly after the moisturizer. It can make a big difference.”

▸ Inquire about diet. If patients or their families tell you they think a particular food triggers the skin reaction, “then you need to act on that,” she said. “Consider allergy testing and dietary avoidance in more severe patients who are not responsive to traditional treatment. I always like to get a nutritionist involved, because if you don't maintain good nutrition, you can have problems. There have been many cases of young children put on dietary manipulation, who go on to have dietary deficiencies, particularly kwashiorkor and even rickets.”

▸ Monitor for infection. Staphylococcus aureus tends to adhere more firmly to the keratinocytes in patients with atopic dermatitis. These patients also show a deficiency in the ability to express antimicrobial peptides, particularly the human β-defensins and cathelicidins. “This probably contributes to the risk of infection and hopefully in the future will translate into some new therapies,” she said.

▸ Try bleach baths. Have patients soak daily in a tub of bathwater that contains one-eighth to one-fourth of a cup of bleach. “With children, they're rarely in a full tub, so you need to back off on some of [the amount of bleach] based on how full the tub is,” she said. “Also consider the use of gentle antibacterial soaps.”

Dr. Paller discussed the case of a 16-month-old boy who had severe atopic dermatitis and skin infections. Despite the vigorous use of topical steroids and basic care, he flared every time his antibiotic was discontinued. “At this point, we introduced a daily bleach bath and it remarkably improved his control and decreased his need for systemic antibiotics,” she said.

Bleach baths are also useful for methicillin-resistant S. aureus infection.

▸ Try compounded topical therapy. She said that patients who are unresponsive to commercially available topical agents almost always respond to compounded triamcinolone (0.025% or 0.1%) and salicylic acid (2%–6%) in petrolatum or Aquaphor. “I tend to use the powder form of triamcinolone; I think that works the best,” she said. “In the younger children I'll never go above 2%–3% salicylic acid.”

She added that patients should be monitored carefully for side effects due to the risk of systemic absorption of the compounded agent. Taper the dosing as patients improve.

▸ Treat certain body sites differently. For example, if the periorbital area is affected, consider introducing calcineurin inhibitors.

“I still have patients who don't understand that it's safe to apply those in the periorbital area,” she said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “I've seen patients who have terrible problems with excessive rubbing of their eyes, even in the face of calcineurin inhibitors. In some of these patients it's important to get them in to an ophthalmologist or an allergist who can help to address the fact that they may have some associated conjunctivitis that's triggering that periocular pruritus.”

For affected areas of the scalp she recommends that patients apply fluocinolone in oil vehicle applied to a wet scalp for as little as an hour before they wash their hair.

If that doesn't work, try compounded triamcinolone and salicylic acid in mineral oil, “but be aware of the potential risks of increased absorption.”

Dr. Paller called hands and feet “the toughest areas that we tend to see.” They typically require an increased potency of any agents used.

When these basic approaches fail or are not tolerated, consider the following: hospitalization to “cool down” the patient; systemic immunosuppressants; ultraviolet light, including narrow-band UVB; and balneotherapy.

“UVB treatment in pediatric patients is very difficult, often because of time constraints, and concern about UV exposure, compliance, and tolerance,” she said.

As for systemic corticosteroids, “we try to avoid long-term use in children because of the many potential side effects including growth failure,” she said. “When you stop someone on systemic corticosteroids, there tends to be a rebound effect.”

The systemic immunosuppressant she uses most often is cyclosporin A. She usually starts with a dose of 5 mg/kg per day (3 mg/kg per day if it's the microemulsion form). “In many cases there's a response within a few weeks,” Dr. Paller said. “In other cases it can take longer, so I will tend to go for a 3-month trial and see how that patient is doing. I always try to taper about 1 mg/kg per day each month as tolerated. I find that many patients cannot get off the medication, but they can be tapered down to a lower level.”

Although use of cyclosporin A requires monitoring of blood pressure and renal and liver function, “I have not had one patient who's had a side effect that's significant from the use of cyclosporine, so I don't hesitate to use it, even in young children if that's necessary.”

If the patient is still not responding, consider the possibility of an alternative diagnosis. Atopic dermatitis impostors can include contact dermatitis, scabies, Wiskott-Aldrich syndrome, hyperimmunoglobulinemia E, and Netherton's syndrome.

“Sometimes we need to step back and ask, 'Do we have the right diagnosis?'” Dr. Paller said.

LAS VEGAS — If you're stumped about how to manage your patients with severe atopic dermatitis, Amy S. Paller, M.D., offered clear-cut advice at the Fall Clinical Dermatology Conference.

“It's important to see if there's a problem with what they're doing on a basic level,” said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago. “How often are they bathing? Once a day or at least every other day? Are they following that with a good thick moisturizer that can improve that underlying skin barrier? What about harsh agents? Are they avoiding bubble baths and harsh soaps? Is there a benefit of a soft water system?”

She offered the following tips for managing these patients:

▸ Consider wrap management. After patients bathe and apply topical medication or moisturizer to their skin, have them put on damp, long underwear-type cotton pajamas and socks. Top this with a dry layer of pajamas and a dry layer of socks. This strategy “decreases the pruritus and discomfort and helps kids fall asleep,” said Dr. Paller, who is also a professor of pediatrics at the university. “In severely affected infants it's been a wonderful addition without doing anything else that might increase the strength of medication that you're using. You can modify this as well for hand dermatitis by putting on damp gloves topped with dry gloves.”

She cautioned that wet wraps “can theoretically increase the absorption of topically applied medications. That's why in my practice I primarily use this directly after the moisturizer. It can make a big difference.”

▸ Inquire about diet. If patients or their families tell you they think a particular food triggers the skin reaction, “then you need to act on that,” she said. “Consider allergy testing and dietary avoidance in more severe patients who are not responsive to traditional treatment. I always like to get a nutritionist involved, because if you don't maintain good nutrition, you can have problems. There have been many cases of young children put on dietary manipulation, who go on to have dietary deficiencies, particularly kwashiorkor and even rickets.”

▸ Monitor for infection. Staphylococcus aureus tends to adhere more firmly to the keratinocytes in patients with atopic dermatitis. These patients also show a deficiency in the ability to express antimicrobial peptides, particularly the human β-defensins and cathelicidins. “This probably contributes to the risk of infection and hopefully in the future will translate into some new therapies,” she said.

▸ Try bleach baths. Have patients soak daily in a tub of bathwater that contains one-eighth to one-fourth of a cup of bleach. “With children, they're rarely in a full tub, so you need to back off on some of [the amount of bleach] based on how full the tub is,” she said. “Also consider the use of gentle antibacterial soaps.”

Dr. Paller discussed the case of a 16-month-old boy who had severe atopic dermatitis and skin infections. Despite the vigorous use of topical steroids and basic care, he flared every time his antibiotic was discontinued. “At this point, we introduced a daily bleach bath and it remarkably improved his control and decreased his need for systemic antibiotics,” she said.

Bleach baths are also useful for methicillin-resistant S. aureus infection.

▸ Try compounded topical therapy. She said that patients who are unresponsive to commercially available topical agents almost always respond to compounded triamcinolone (0.025% or 0.1%) and salicylic acid (2%–6%) in petrolatum or Aquaphor. “I tend to use the powder form of triamcinolone; I think that works the best,” she said. “In the younger children I'll never go above 2%–3% salicylic acid.”

She added that patients should be monitored carefully for side effects due to the risk of systemic absorption of the compounded agent. Taper the dosing as patients improve.

▸ Treat certain body sites differently. For example, if the periorbital area is affected, consider introducing calcineurin inhibitors.

“I still have patients who don't understand that it's safe to apply those in the periorbital area,” she said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “I've seen patients who have terrible problems with excessive rubbing of their eyes, even in the face of calcineurin inhibitors. In some of these patients it's important to get them in to an ophthalmologist or an allergist who can help to address the fact that they may have some associated conjunctivitis that's triggering that periocular pruritus.”

For affected areas of the scalp she recommends that patients apply fluocinolone in oil vehicle applied to a wet scalp for as little as an hour before they wash their hair.

If that doesn't work, try compounded triamcinolone and salicylic acid in mineral oil, “but be aware of the potential risks of increased absorption.”

Dr. Paller called hands and feet “the toughest areas that we tend to see.” They typically require an increased potency of any agents used.

When these basic approaches fail or are not tolerated, consider the following: hospitalization to “cool down” the patient; systemic immunosuppressants; ultraviolet light, including narrow-band UVB; and balneotherapy.

“UVB treatment in pediatric patients is very difficult, often because of time constraints, and concern about UV exposure, compliance, and tolerance,” she said.

As for systemic corticosteroids, “we try to avoid long-term use in children because of the many potential side effects including growth failure,” she said. “When you stop someone on systemic corticosteroids, there tends to be a rebound effect.”

The systemic immunosuppressant she uses most often is cyclosporin A. She usually starts with a dose of 5 mg/kg per day (3 mg/kg per day if it's the microemulsion form). “In many cases there's a response within a few weeks,” Dr. Paller said. “In other cases it can take longer, so I will tend to go for a 3-month trial and see how that patient is doing. I always try to taper about 1 mg/kg per day each month as tolerated. I find that many patients cannot get off the medication, but they can be tapered down to a lower level.”

Although use of cyclosporin A requires monitoring of blood pressure and renal and liver function, “I have not had one patient who's had a side effect that's significant from the use of cyclosporine, so I don't hesitate to use it, even in young children if that's necessary.”

If the patient is still not responding, consider the possibility of an alternative diagnosis. Atopic dermatitis impostors can include contact dermatitis, scabies, Wiskott-Aldrich syndrome, hyperimmunoglobulinemia E, and Netherton's syndrome.

“Sometimes we need to step back and ask, 'Do we have the right diagnosis?'” Dr. Paller said.

LAS VEGAS — If you're stumped about how to manage your patients with severe atopic dermatitis, Amy S. Paller, M.D., offered clear-cut advice at the Fall Clinical Dermatology Conference.

“It's important to see if there's a problem with what they're doing on a basic level,” said Dr. Paller, professor and chair of dermatology at Northwestern University, Chicago. “How often are they bathing? Once a day or at least every other day? Are they following that with a good thick moisturizer that can improve that underlying skin barrier? What about harsh agents? Are they avoiding bubble baths and harsh soaps? Is there a benefit of a soft water system?”

She offered the following tips for managing these patients:

▸ Consider wrap management. After patients bathe and apply topical medication or moisturizer to their skin, have them put on damp, long underwear-type cotton pajamas and socks. Top this with a dry layer of pajamas and a dry layer of socks. This strategy “decreases the pruritus and discomfort and helps kids fall asleep,” said Dr. Paller, who is also a professor of pediatrics at the university. “In severely affected infants it's been a wonderful addition without doing anything else that might increase the strength of medication that you're using. You can modify this as well for hand dermatitis by putting on damp gloves topped with dry gloves.”

She cautioned that wet wraps “can theoretically increase the absorption of topically applied medications. That's why in my practice I primarily use this directly after the moisturizer. It can make a big difference.”

▸ Inquire about diet. If patients or their families tell you they think a particular food triggers the skin reaction, “then you need to act on that,” she said. “Consider allergy testing and dietary avoidance in more severe patients who are not responsive to traditional treatment. I always like to get a nutritionist involved, because if you don't maintain good nutrition, you can have problems. There have been many cases of young children put on dietary manipulation, who go on to have dietary deficiencies, particularly kwashiorkor and even rickets.”

▸ Monitor for infection. Staphylococcus aureus tends to adhere more firmly to the keratinocytes in patients with atopic dermatitis. These patients also show a deficiency in the ability to express antimicrobial peptides, particularly the human β-defensins and cathelicidins. “This probably contributes to the risk of infection and hopefully in the future will translate into some new therapies,” she said.

▸ Try bleach baths. Have patients soak daily in a tub of bathwater that contains one-eighth to one-fourth of a cup of bleach. “With children, they're rarely in a full tub, so you need to back off on some of [the amount of bleach] based on how full the tub is,” she said. “Also consider the use of gentle antibacterial soaps.”

Dr. Paller discussed the case of a 16-month-old boy who had severe atopic dermatitis and skin infections. Despite the vigorous use of topical steroids and basic care, he flared every time his antibiotic was discontinued. “At this point, we introduced a daily bleach bath and it remarkably improved his control and decreased his need for systemic antibiotics,” she said.

Bleach baths are also useful for methicillin-resistant S. aureus infection.

▸ Try compounded topical therapy. She said that patients who are unresponsive to commercially available topical agents almost always respond to compounded triamcinolone (0.025% or 0.1%) and salicylic acid (2%–6%) in petrolatum or Aquaphor. “I tend to use the powder form of triamcinolone; I think that works the best,” she said. “In the younger children I'll never go above 2%–3% salicylic acid.”

She added that patients should be monitored carefully for side effects due to the risk of systemic absorption of the compounded agent. Taper the dosing as patients improve.

▸ Treat certain body sites differently. For example, if the periorbital area is affected, consider introducing calcineurin inhibitors.

“I still have patients who don't understand that it's safe to apply those in the periorbital area,” she said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “I've seen patients who have terrible problems with excessive rubbing of their eyes, even in the face of calcineurin inhibitors. In some of these patients it's important to get them in to an ophthalmologist or an allergist who can help to address the fact that they may have some associated conjunctivitis that's triggering that periocular pruritus.”

For affected areas of the scalp she recommends that patients apply fluocinolone in oil vehicle applied to a wet scalp for as little as an hour before they wash their hair.

If that doesn't work, try compounded triamcinolone and salicylic acid in mineral oil, “but be aware of the potential risks of increased absorption.”

Dr. Paller called hands and feet “the toughest areas that we tend to see.” They typically require an increased potency of any agents used.

When these basic approaches fail or are not tolerated, consider the following: hospitalization to “cool down” the patient; systemic immunosuppressants; ultraviolet light, including narrow-band UVB; and balneotherapy.

“UVB treatment in pediatric patients is very difficult, often because of time constraints, and concern about UV exposure, compliance, and tolerance,” she said.

As for systemic corticosteroids, “we try to avoid long-term use in children because of the many potential side effects including growth failure,” she said. “When you stop someone on systemic corticosteroids, there tends to be a rebound effect.”

The systemic immunosuppressant she uses most often is cyclosporin A. She usually starts with a dose of 5 mg/kg per day (3 mg/kg per day if it's the microemulsion form). “In many cases there's a response within a few weeks,” Dr. Paller said. “In other cases it can take longer, so I will tend to go for a 3-month trial and see how that patient is doing. I always try to taper about 1 mg/kg per day each month as tolerated. I find that many patients cannot get off the medication, but they can be tapered down to a lower level.”

Although use of cyclosporin A requires monitoring of blood pressure and renal and liver function, “I have not had one patient who's had a side effect that's significant from the use of cyclosporine, so I don't hesitate to use it, even in young children if that's necessary.”

If the patient is still not responding, consider the possibility of an alternative diagnosis. Atopic dermatitis impostors can include contact dermatitis, scabies, Wiskott-Aldrich syndrome, hyperimmunoglobulinemia E, and Netherton's syndrome.

“Sometimes we need to step back and ask, 'Do we have the right diagnosis?'” Dr. Paller said.

LOS ANGELES — Claudication in peripheral arterial disease can present in many different ways, a fact that isn't always appreciated by physicians, Allan V. Abbott, M.D., said at the annual meeting of the California Academy of Family Physicians.

About 33% of patients with peripheral arterial disease (PAD) present with classic claudication, “which means that pain comes on during exercise but goes away within 10 minutes of rest,” said Dr. Abbott, professor of family medicine at the University of Southern California, Los Angeles.

Another one-third will have atypical exertional leg pain symptoms, “which means that they have similar pain but it doesn't cause them to stop walking,” or they have similar pain that that does not involve the calves or does not resolve within 10 minutes of rest.

As for the remaining patients, he said, “some of them will have pain both at rest and on exertion, a few of them will have no exertional leg pain and be physically active, and some won't have any exertional leg pain because they aren't active.”

In the general population, claudication affects 10% of people over age 70 years compared with just 1%–2% of those aged 37–69 years.

In your differential diagnosis, nonvascular causes of claudication include arthritis of the hips, restless leg syndrome, peripheral neuropathies, spinal stenosis, and a prolapsed intervertebral disk. Vascular causes include thromboangiitis obliterans (Buerger's disease), and deep venous thrombosis.

Most of the lesions in PAD occur in the middle part of the leg around the knee. The most common kind of claudication occurs in the calf. “It's most commonly in the upper part of the calf,” said Dr. Abbott, who is also associate dean for curriculum and continuing medical education at the Keck School of Medicine in Los Angeles. “That's usually due to superficial femoral artery stenosis.”

Claudication that occurs in the lower third of the calf is usually due to popliteal disease. Thigh claudication can happen occasionally, usually due to femoral artery stenosis, while foot claudication “is really rare,” he said.

Buttock and hip claudication can occur from aortoiliac disease. “After you've ruled out arthritis, patients with aortoiliac disease will generally be impotent,” Dr. Abbott said. “If they are not impotent, chances are they don't have serious vascular disease at all.”

If you suspect PAD, the ankle-brachial index (ABI) is an effective noninvasive test for diagnosis. “Examination of pulses alone is not a reliable way to diagnose PAD,” he said.

In patients with PAD, the resting systolic pressure in the ankle should equal or exceed that of the arm. Any time the ABI ratio is below 0.9, “it's abnormal, it's PAD,” he said. “If it's between 0.5 and 0.9 it's mild to moderate. If it's less than 0.5 it's severe.”

When ABI indicates PAD, the level and extent of disease are determined by segmental limb pressure testing. “This can be done in your office but it's more commonly done in the vascular lab,” he said.

Other noninvasive tests for PAD include exercise treadmill tests, segmental volume plethysmography, ultrasonography, MRI, and magnetic resonance angiography.

Chronic Arterial Insufficiency Signs

Limb exam (and comparison with the opposite limb) includes:

▸ Hair loss.

▸ Poor nail growth (brittle nails).

▸ Dry, scaly, atrophic skin.

▸ Dependent rubor (redness).

▸ Pallor with leg elevation after 1 minute at 60 degrees. Normal color should return in 10–15 seconds. If it takes longer than 40 seconds, this indicates severe ischemia.

▸ Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene.

▸ Absent or diminished femoral or pedal pulses, especially after exercising the limb.

▸ Arterial bruits.

Source: Dr. Abbott

LOS ANGELES — Claudication in peripheral arterial disease can present in many different ways, a fact that isn't always appreciated by physicians, Allan V. Abbott, M.D., said at the annual meeting of the California Academy of Family Physicians.

About 33% of patients with peripheral arterial disease (PAD) present with classic claudication, “which means that pain comes on during exercise but goes away within 10 minutes of rest,” said Dr. Abbott, professor of family medicine at the University of Southern California, Los Angeles.

Another one-third will have atypical exertional leg pain symptoms, “which means that they have similar pain but it doesn't cause them to stop walking,” or they have similar pain that that does not involve the calves or does not resolve within 10 minutes of rest.

As for the remaining patients, he said, “some of them will have pain both at rest and on exertion, a few of them will have no exertional leg pain and be physically active, and some won't have any exertional leg pain because they aren't active.”

In the general population, claudication affects 10% of people over age 70 years compared with just 1%–2% of those aged 37–69 years.

In your differential diagnosis, nonvascular causes of claudication include arthritis of the hips, restless leg syndrome, peripheral neuropathies, spinal stenosis, and a prolapsed intervertebral disk. Vascular causes include thromboangiitis obliterans (Buerger's disease), and deep venous thrombosis.

Most of the lesions in PAD occur in the middle part of the leg around the knee. The most common kind of claudication occurs in the calf. “It's most commonly in the upper part of the calf,” said Dr. Abbott, who is also associate dean for curriculum and continuing medical education at the Keck School of Medicine in Los Angeles. “That's usually due to superficial femoral artery stenosis.”

Claudication that occurs in the lower third of the calf is usually due to popliteal disease. Thigh claudication can happen occasionally, usually due to femoral artery stenosis, while foot claudication “is really rare,” he said.

Buttock and hip claudication can occur from aortoiliac disease. “After you've ruled out arthritis, patients with aortoiliac disease will generally be impotent,” Dr. Abbott said. “If they are not impotent, chances are they don't have serious vascular disease at all.”

If you suspect PAD, the ankle-brachial index (ABI) is an effective noninvasive test for diagnosis. “Examination of pulses alone is not a reliable way to diagnose PAD,” he said.

In patients with PAD, the resting systolic pressure in the ankle should equal or exceed that of the arm. Any time the ABI ratio is below 0.9, “it's abnormal, it's PAD,” he said. “If it's between 0.5 and 0.9 it's mild to moderate. If it's less than 0.5 it's severe.”

When ABI indicates PAD, the level and extent of disease are determined by segmental limb pressure testing. “This can be done in your office but it's more commonly done in the vascular lab,” he said.

Other noninvasive tests for PAD include exercise treadmill tests, segmental volume plethysmography, ultrasonography, MRI, and magnetic resonance angiography.

Chronic Arterial Insufficiency Signs

Limb exam (and comparison with the opposite limb) includes:

▸ Hair loss.

▸ Poor nail growth (brittle nails).

▸ Dry, scaly, atrophic skin.

▸ Dependent rubor (redness).

▸ Pallor with leg elevation after 1 minute at 60 degrees. Normal color should return in 10–15 seconds. If it takes longer than 40 seconds, this indicates severe ischemia.

▸ Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene.

▸ Absent or diminished femoral or pedal pulses, especially after exercising the limb.

▸ Arterial bruits.

Source: Dr. Abbott

LOS ANGELES — Claudication in peripheral arterial disease can present in many different ways, a fact that isn't always appreciated by physicians, Allan V. Abbott, M.D., said at the annual meeting of the California Academy of Family Physicians.

About 33% of patients with peripheral arterial disease (PAD) present with classic claudication, “which means that pain comes on during exercise but goes away within 10 minutes of rest,” said Dr. Abbott, professor of family medicine at the University of Southern California, Los Angeles.

Another one-third will have atypical exertional leg pain symptoms, “which means that they have similar pain but it doesn't cause them to stop walking,” or they have similar pain that that does not involve the calves or does not resolve within 10 minutes of rest.

As for the remaining patients, he said, “some of them will have pain both at rest and on exertion, a few of them will have no exertional leg pain and be physically active, and some won't have any exertional leg pain because they aren't active.”

In the general population, claudication affects 10% of people over age 70 years compared with just 1%–2% of those aged 37–69 years.

In your differential diagnosis, nonvascular causes of claudication include arthritis of the hips, restless leg syndrome, peripheral neuropathies, spinal stenosis, and a prolapsed intervertebral disk. Vascular causes include thromboangiitis obliterans (Buerger's disease), and deep venous thrombosis.

Most of the lesions in PAD occur in the middle part of the leg around the knee. The most common kind of claudication occurs in the calf. “It's most commonly in the upper part of the calf,” said Dr. Abbott, who is also associate dean for curriculum and continuing medical education at the Keck School of Medicine in Los Angeles. “That's usually due to superficial femoral artery stenosis.”

Claudication that occurs in the lower third of the calf is usually due to popliteal disease. Thigh claudication can happen occasionally, usually due to femoral artery stenosis, while foot claudication “is really rare,” he said.

Buttock and hip claudication can occur from aortoiliac disease. “After you've ruled out arthritis, patients with aortoiliac disease will generally be impotent,” Dr. Abbott said. “If they are not impotent, chances are they don't have serious vascular disease at all.”

If you suspect PAD, the ankle-brachial index (ABI) is an effective noninvasive test for diagnosis. “Examination of pulses alone is not a reliable way to diagnose PAD,” he said.

In patients with PAD, the resting systolic pressure in the ankle should equal or exceed that of the arm. Any time the ABI ratio is below 0.9, “it's abnormal, it's PAD,” he said. “If it's between 0.5 and 0.9 it's mild to moderate. If it's less than 0.5 it's severe.”

When ABI indicates PAD, the level and extent of disease are determined by segmental limb pressure testing. “This can be done in your office but it's more commonly done in the vascular lab,” he said.

Other noninvasive tests for PAD include exercise treadmill tests, segmental volume plethysmography, ultrasonography, MRI, and magnetic resonance angiography.

Chronic Arterial Insufficiency Signs

Limb exam (and comparison with the opposite limb) includes:

▸ Hair loss.

▸ Poor nail growth (brittle nails).

▸ Dry, scaly, atrophic skin.

▸ Dependent rubor (redness).

▸ Pallor with leg elevation after 1 minute at 60 degrees. Normal color should return in 10–15 seconds. If it takes longer than 40 seconds, this indicates severe ischemia.

▸ Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene.

▸ Absent or diminished femoral or pedal pulses, especially after exercising the limb.

▸ Arterial bruits.

Source: Dr. Abbott

SAN DIEGO – A specific warning issued in June 2003 by the United Kingdom Committee on Safety of Medicines that advised physicians not to use paroxetine in patients younger than 18 years of age significantly influenced how the drug was prescribed in young patients in Ontario.

Yet subsequent, more generalized warnings about selective serotonin reuptake inhibitors (SSRIs) issued in the United States and Canada did not influence antidepressant prescription trends in any age group of Ontario residents, Paul A. Kurdyak, M.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

The finding suggests that, at least for the population studied, specific drug warnings influence prescribing habits more do than general warnings.

“From a policy perspective, vague warnings don't do anything in Ontario,” Dr. Kurdyak, a research fellow in the department of psychiatry at the University of Toronto, said in an interview. “I don't know about the United States. It might be different there because you're more litigious here than we [in Canada] are.”

In a study supported by AstraZeneca Pharmaceuticals and the Canadian Institute of Health Research, Dr. Kurdyak and his associates analyzed new antidepressant prescriptions dispensed by the Ontario Drug Benefits Program between April 1998 and March 2005. Three age groups were studied: younger than 20 years, 20–65 years, and 66 years and older.

The investigators conducted a time-series analysis to assess the impact of five advisory dates on the prescription of antidepressants. Those dates were:

▸ June 10, 2003. UK Committee on the Safety of Medicine advises against the use of paroxetine in patients under 18 years of age with depression.

▸ Oct. 27, 2003. The U.S. Food and Drug Administration issues a more general public health advisory emphasizing that newer antidepressants should be used with caution in children.

▸ March 22, 2004. The FDA issues a public health advisory about the need to closely monitor patients of all ages for worsening depression or suicidality after initiation of antidepressant therapy.

▸ June 3, 2004. Health Care Canada follows suit with a similar warning.

▸ Oct. 15, 2004. The FDA issues a black box warning for the use of antidepressants in pediatric patients.

Analysis revealed that the mean number of monthly new prescriptions for any SSRI per 10,000 individuals was 5.5 for patients younger than 20 years; 29.7 for patients aged 20–65 years, and 16.4 for patients aged 66 years and older.

“The number of new prescriptions for SSRIs as a group did not change after any antidepressant warning in any age group,” the investigators wrote in their poster. “However, the rate of new paroxetine prescriptions in patients younger than 20 years of age declined by 54% immediately following the first UK warning for paroxetine in June 2003.”

That particular warning “had no effect on new paroxetine prescriptions in the other age categories, [and] no warnings influenced new prescription rates for any other antidepressants in any other age group,” they added.

SAN DIEGO – A specific warning issued in June 2003 by the United Kingdom Committee on Safety of Medicines that advised physicians not to use paroxetine in patients younger than 18 years of age significantly influenced how the drug was prescribed in young patients in Ontario.

Yet subsequent, more generalized warnings about selective serotonin reuptake inhibitors (SSRIs) issued in the United States and Canada did not influence antidepressant prescription trends in any age group of Ontario residents, Paul A. Kurdyak, M.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

The finding suggests that, at least for the population studied, specific drug warnings influence prescribing habits more do than general warnings.

“From a policy perspective, vague warnings don't do anything in Ontario,” Dr. Kurdyak, a research fellow in the department of psychiatry at the University of Toronto, said in an interview. “I don't know about the United States. It might be different there because you're more litigious here than we [in Canada] are.”

In a study supported by AstraZeneca Pharmaceuticals and the Canadian Institute of Health Research, Dr. Kurdyak and his associates analyzed new antidepressant prescriptions dispensed by the Ontario Drug Benefits Program between April 1998 and March 2005. Three age groups were studied: younger than 20 years, 20–65 years, and 66 years and older.

The investigators conducted a time-series analysis to assess the impact of five advisory dates on the prescription of antidepressants. Those dates were:

▸ June 10, 2003. UK Committee on the Safety of Medicine advises against the use of paroxetine in patients under 18 years of age with depression.

▸ Oct. 27, 2003. The U.S. Food and Drug Administration issues a more general public health advisory emphasizing that newer antidepressants should be used with caution in children.

▸ March 22, 2004. The FDA issues a public health advisory about the need to closely monitor patients of all ages for worsening depression or suicidality after initiation of antidepressant therapy.

▸ June 3, 2004. Health Care Canada follows suit with a similar warning.

▸ Oct. 15, 2004. The FDA issues a black box warning for the use of antidepressants in pediatric patients.

Analysis revealed that the mean number of monthly new prescriptions for any SSRI per 10,000 individuals was 5.5 for patients younger than 20 years; 29.7 for patients aged 20–65 years, and 16.4 for patients aged 66 years and older.

“The number of new prescriptions for SSRIs as a group did not change after any antidepressant warning in any age group,” the investigators wrote in their poster. “However, the rate of new paroxetine prescriptions in patients younger than 20 years of age declined by 54% immediately following the first UK warning for paroxetine in June 2003.”

That particular warning “had no effect on new paroxetine prescriptions in the other age categories, [and] no warnings influenced new prescription rates for any other antidepressants in any other age group,” they added.

SAN DIEGO – A specific warning issued in June 2003 by the United Kingdom Committee on Safety of Medicines that advised physicians not to use paroxetine in patients younger than 18 years of age significantly influenced how the drug was prescribed in young patients in Ontario.

Yet subsequent, more generalized warnings about selective serotonin reuptake inhibitors (SSRIs) issued in the United States and Canada did not influence antidepressant prescription trends in any age group of Ontario residents, Paul A. Kurdyak, M.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

The finding suggests that, at least for the population studied, specific drug warnings influence prescribing habits more do than general warnings.

“From a policy perspective, vague warnings don't do anything in Ontario,” Dr. Kurdyak, a research fellow in the department of psychiatry at the University of Toronto, said in an interview. “I don't know about the United States. It might be different there because you're more litigious here than we [in Canada] are.”

In a study supported by AstraZeneca Pharmaceuticals and the Canadian Institute of Health Research, Dr. Kurdyak and his associates analyzed new antidepressant prescriptions dispensed by the Ontario Drug Benefits Program between April 1998 and March 2005. Three age groups were studied: younger than 20 years, 20–65 years, and 66 years and older.

The investigators conducted a time-series analysis to assess the impact of five advisory dates on the prescription of antidepressants. Those dates were:

▸ June 10, 2003. UK Committee on the Safety of Medicine advises against the use of paroxetine in patients under 18 years of age with depression.

▸ Oct. 27, 2003. The U.S. Food and Drug Administration issues a more general public health advisory emphasizing that newer antidepressants should be used with caution in children.

▸ March 22, 2004. The FDA issues a public health advisory about the need to closely monitor patients of all ages for worsening depression or suicidality after initiation of antidepressant therapy.

▸ June 3, 2004. Health Care Canada follows suit with a similar warning.

▸ Oct. 15, 2004. The FDA issues a black box warning for the use of antidepressants in pediatric patients.

Analysis revealed that the mean number of monthly new prescriptions for any SSRI per 10,000 individuals was 5.5 for patients younger than 20 years; 29.7 for patients aged 20–65 years, and 16.4 for patients aged 66 years and older.

“The number of new prescriptions for SSRIs as a group did not change after any antidepressant warning in any age group,” the investigators wrote in their poster. “However, the rate of new paroxetine prescriptions in patients younger than 20 years of age declined by 54% immediately following the first UK warning for paroxetine in June 2003.”

That particular warning “had no effect on new paroxetine prescriptions in the other age categories, [and] no warnings influenced new prescription rates for any other antidepressants in any other age group,” they added.

SAN DIEGO – Dialectical behavior therapy shows promise for emotionally troubled youths who are transitioning from state-run child services to state-run adult services, according to the results from a pilot study.

The finding marks the first time dialectical behavior therapy (DBT) has been applied to this segment of the population, Jaak Rakfeldt, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“This is a group of young people who have lived in multiple foster care placements, have been abandoned, neglected, abused, and traumatized,” said Dr. Rakfeldt, a psychologist in the department of social work at Southern Connecticut State University, New Haven. “They end up with all sorts of developmental problems: cognitive deficits, emerging mental illness, substance abuse issues, and high-risk behaviors. At 18 years old, they're aging out of the department of youth services, so they're a very challenging group to work with.”

For the study, 15 participants of a residential program for transitional youths in Connecticut underwent sessions with individual therapists, psychiatrists, and around-the-clock services from residential staff and case managers over a period of 17 months.

Seven of the 15 also received about 12 months of DBT, which blends cognitive-behavioral approaches with acceptance-based practices. The treatment was developed by Marsha M. Linehan, Ph.D., a psychologist who directs the Behavioral and Research & Therapy Clinics at the University of Washington, Seattle.

In an interview, Dr. Rakfeldt described the therapy as “highly structured, and it puts into the center of it mindfulness, which is almost like a Zen technique of emptying oneself and getting oneself emotionally balanced.”

He had a hunch that component of DBT would help these youngsters, whose chief problems included emotional dysregulation and acting out.

“If they get frustrated they punch somebody or they act out,” he said. “If they can learn these skills of emotion regulation and distress tolerance, interpersonal effectiveness, and mindfulness, perhaps they can learn new coping mechanisms that are more appropriate to the world. That's the idea.”

Quantitative measures for all study participants included the Modified Global Assessment of Functioning Scale and the Purposeful Productive Activity and Quality of Life Scale.

Over the 17-month period, those who received DBT showed improvements in global functioning, social relationships, and productive use of time or “intentionality” compared with their counterparts who did not receive DBT, but there were no differences between the two groups in terms of vocational functioning.

In the text of the poster, the investigators noted that the results for the qualitative analysis suggest that the members of the dialectical behavior therapy group “used the groups to work on specific interpersonal relationships, emotion regulation, and distress tolerance skills, as well as to get feedback and support from others in the group. The most important theme was that they felt they had a safe place to practice new behaviors.”

Limitations of the study included the small sample size and its lack of random assignment to the DBT treatment group. Dr. Rakfeldt, also of Yale University, New Haven, estimated that future studies would need to be twice as large to draw strong inferences.

SAN DIEGO – Dialectical behavior therapy shows promise for emotionally troubled youths who are transitioning from state-run child services to state-run adult services, according to the results from a pilot study.

The finding marks the first time dialectical behavior therapy (DBT) has been applied to this segment of the population, Jaak Rakfeldt, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“This is a group of young people who have lived in multiple foster care placements, have been abandoned, neglected, abused, and traumatized,” said Dr. Rakfeldt, a psychologist in the department of social work at Southern Connecticut State University, New Haven. “They end up with all sorts of developmental problems: cognitive deficits, emerging mental illness, substance abuse issues, and high-risk behaviors. At 18 years old, they're aging out of the department of youth services, so they're a very challenging group to work with.”

For the study, 15 participants of a residential program for transitional youths in Connecticut underwent sessions with individual therapists, psychiatrists, and around-the-clock services from residential staff and case managers over a period of 17 months.

Seven of the 15 also received about 12 months of DBT, which blends cognitive-behavioral approaches with acceptance-based practices. The treatment was developed by Marsha M. Linehan, Ph.D., a psychologist who directs the Behavioral and Research & Therapy Clinics at the University of Washington, Seattle.

In an interview, Dr. Rakfeldt described the therapy as “highly structured, and it puts into the center of it mindfulness, which is almost like a Zen technique of emptying oneself and getting oneself emotionally balanced.”

He had a hunch that component of DBT would help these youngsters, whose chief problems included emotional dysregulation and acting out.

“If they get frustrated they punch somebody or they act out,” he said. “If they can learn these skills of emotion regulation and distress tolerance, interpersonal effectiveness, and mindfulness, perhaps they can learn new coping mechanisms that are more appropriate to the world. That's the idea.”

Quantitative measures for all study participants included the Modified Global Assessment of Functioning Scale and the Purposeful Productive Activity and Quality of Life Scale.

Over the 17-month period, those who received DBT showed improvements in global functioning, social relationships, and productive use of time or “intentionality” compared with their counterparts who did not receive DBT, but there were no differences between the two groups in terms of vocational functioning.

In the text of the poster, the investigators noted that the results for the qualitative analysis suggest that the members of the dialectical behavior therapy group “used the groups to work on specific interpersonal relationships, emotion regulation, and distress tolerance skills, as well as to get feedback and support from others in the group. The most important theme was that they felt they had a safe place to practice new behaviors.”

Limitations of the study included the small sample size and its lack of random assignment to the DBT treatment group. Dr. Rakfeldt, also of Yale University, New Haven, estimated that future studies would need to be twice as large to draw strong inferences.

SAN DIEGO – Dialectical behavior therapy shows promise for emotionally troubled youths who are transitioning from state-run child services to state-run adult services, according to the results from a pilot study.

The finding marks the first time dialectical behavior therapy (DBT) has been applied to this segment of the population, Jaak Rakfeldt, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“This is a group of young people who have lived in multiple foster care placements, have been abandoned, neglected, abused, and traumatized,” said Dr. Rakfeldt, a psychologist in the department of social work at Southern Connecticut State University, New Haven. “They end up with all sorts of developmental problems: cognitive deficits, emerging mental illness, substance abuse issues, and high-risk behaviors. At 18 years old, they're aging out of the department of youth services, so they're a very challenging group to work with.”

For the study, 15 participants of a residential program for transitional youths in Connecticut underwent sessions with individual therapists, psychiatrists, and around-the-clock services from residential staff and case managers over a period of 17 months.

Seven of the 15 also received about 12 months of DBT, which blends cognitive-behavioral approaches with acceptance-based practices. The treatment was developed by Marsha M. Linehan, Ph.D., a psychologist who directs the Behavioral and Research & Therapy Clinics at the University of Washington, Seattle.

In an interview, Dr. Rakfeldt described the therapy as “highly structured, and it puts into the center of it mindfulness, which is almost like a Zen technique of emptying oneself and getting oneself emotionally balanced.”

He had a hunch that component of DBT would help these youngsters, whose chief problems included emotional dysregulation and acting out.

“If they get frustrated they punch somebody or they act out,” he said. “If they can learn these skills of emotion regulation and distress tolerance, interpersonal effectiveness, and mindfulness, perhaps they can learn new coping mechanisms that are more appropriate to the world. That's the idea.”

Quantitative measures for all study participants included the Modified Global Assessment of Functioning Scale and the Purposeful Productive Activity and Quality of Life Scale.

Over the 17-month period, those who received DBT showed improvements in global functioning, social relationships, and productive use of time or “intentionality” compared with their counterparts who did not receive DBT, but there were no differences between the two groups in terms of vocational functioning.

In the text of the poster, the investigators noted that the results for the qualitative analysis suggest that the members of the dialectical behavior therapy group “used the groups to work on specific interpersonal relationships, emotion regulation, and distress tolerance skills, as well as to get feedback and support from others in the group. The most important theme was that they felt they had a safe place to practice new behaviors.”

Limitations of the study included the small sample size and its lack of random assignment to the DBT treatment group. Dr. Rakfeldt, also of Yale University, New Haven, estimated that future studies would need to be twice as large to draw strong inferences.

SAN DIEGO – The presence or absence of body image distortion can help clinicians identify two distinct groups of latency-age children who present with severe food refusal, Robyn S. Mehlenbeck, Ph.D., reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The finding is important because latency-age patients do not fit neatly into categories of anorexia or feeding disorder of early childhood, said Dr. Mehlenbeck of the department of psychiatry at Rhode Island Hospital, Brown Medical School, Providence, R.I.

“There's a lot of confusion about these kids who don't fit [a definition] and we really don't know what to call them, let alone what to do with them,” she said, adding that there are no good estimates on the number of younger children with eating disorders.

She and her associates reviewed the medical charts of 44 patients, aged 6–12 years, who presented with food refusal and restrictive eating habits to a day treatment program at Rhode Island Hospital between 1999 and 2003. The treatment program takes a multidisciplinary team approach, collaborating closely with families and community providers.

At intake, families completed questionnaires about behavioral and family functioning, and quality of life. The mean age of study participants was 10 years, and more than half of the participants were female (67%). Most were white (82%), and 30% were on public insurance. The average length of stay in the program was 21 days.

The investigators divided the children into two groups. The 16 children who presented with body image distortion were called the early onset anorexia (EOA) group, while the 28 who presented with no body image distortion were called the atypical eating disorder (AED) group.

The two groups of children did not differ in terms of gender, insurance type, or program length of stay, but children in the AED group were about 2 years younger than their EOA counterparts (a mean of 9.7 years vs. 11.4 years, respectively).

All eight children from minority backgrounds were in the atypical eating disorder group; the children in the AED group were more likely to come from single-parent households than were those in the early onset anorexia group.

The two groups did not differ in terms of body mass index and most medical factors, but those in the EOA group were more likely to show cardiovascular compromise, exercise excessively, and have a family history of eating disorders, compared with the children in the AED group.

In addition, nearly 90% of the children in the EOA group had recent weight loss prior to starting the treatment program, compared with about 50% of those in the AED group. Of the children who had weight loss, the mean loss was 19.7 pounds in the EOA group, compared with a mean of 8.3 pounds in the AED group.

On the flip side, children in the AED group were more likely than their EOA counterparts to be described by their parents as having a history of picky eating, poor appetite, sensitivity to textures, slow eating, and difficulty swallowing.

Dr. Mehlenbeck said that the treatment implications differ for these two groups of children. “We would treat AED kids more behaviorally, similar to kids with anxiety and behavior disorders,” she said. “Treatment for kids with EOA would be similar to interventions for anorexia.”

Identifying children with food refusal problems early “may help quite a bit,” she added. “Collaboration is key. All of these kids need to be treated with a team format. So even if they're an outpatient, pediatricians should be working with a mental health worker who specializes in feeding or eating disorders, and a dietitian.”

SAN DIEGO – The presence or absence of body image distortion can help clinicians identify two distinct groups of latency-age children who present with severe food refusal, Robyn S. Mehlenbeck, Ph.D., reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The finding is important because latency-age patients do not fit neatly into categories of anorexia or feeding disorder of early childhood, said Dr. Mehlenbeck of the department of psychiatry at Rhode Island Hospital, Brown Medical School, Providence, R.I.

“There's a lot of confusion about these kids who don't fit [a definition] and we really don't know what to call them, let alone what to do with them,” she said, adding that there are no good estimates on the number of younger children with eating disorders.

She and her associates reviewed the medical charts of 44 patients, aged 6–12 years, who presented with food refusal and restrictive eating habits to a day treatment program at Rhode Island Hospital between 1999 and 2003. The treatment program takes a multidisciplinary team approach, collaborating closely with families and community providers.

At intake, families completed questionnaires about behavioral and family functioning, and quality of life. The mean age of study participants was 10 years, and more than half of the participants were female (67%). Most were white (82%), and 30% were on public insurance. The average length of stay in the program was 21 days.

The investigators divided the children into two groups. The 16 children who presented with body image distortion were called the early onset anorexia (EOA) group, while the 28 who presented with no body image distortion were called the atypical eating disorder (AED) group.

The two groups of children did not differ in terms of gender, insurance type, or program length of stay, but children in the AED group were about 2 years younger than their EOA counterparts (a mean of 9.7 years vs. 11.4 years, respectively).

All eight children from minority backgrounds were in the atypical eating disorder group; the children in the AED group were more likely to come from single-parent households than were those in the early onset anorexia group.

The two groups did not differ in terms of body mass index and most medical factors, but those in the EOA group were more likely to show cardiovascular compromise, exercise excessively, and have a family history of eating disorders, compared with the children in the AED group.

In addition, nearly 90% of the children in the EOA group had recent weight loss prior to starting the treatment program, compared with about 50% of those in the AED group. Of the children who had weight loss, the mean loss was 19.7 pounds in the EOA group, compared with a mean of 8.3 pounds in the AED group.

On the flip side, children in the AED group were more likely than their EOA counterparts to be described by their parents as having a history of picky eating, poor appetite, sensitivity to textures, slow eating, and difficulty swallowing.

Dr. Mehlenbeck said that the treatment implications differ for these two groups of children. “We would treat AED kids more behaviorally, similar to kids with anxiety and behavior disorders,” she said. “Treatment for kids with EOA would be similar to interventions for anorexia.”

Identifying children with food refusal problems early “may help quite a bit,” she added. “Collaboration is key. All of these kids need to be treated with a team format. So even if they're an outpatient, pediatricians should be working with a mental health worker who specializes in feeding or eating disorders, and a dietitian.”

SAN DIEGO – The presence or absence of body image distortion can help clinicians identify two distinct groups of latency-age children who present with severe food refusal, Robyn S. Mehlenbeck, Ph.D., reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The finding is important because latency-age patients do not fit neatly into categories of anorexia or feeding disorder of early childhood, said Dr. Mehlenbeck of the department of psychiatry at Rhode Island Hospital, Brown Medical School, Providence, R.I.

“There's a lot of confusion about these kids who don't fit [a definition] and we really don't know what to call them, let alone what to do with them,” she said, adding that there are no good estimates on the number of younger children with eating disorders.

She and her associates reviewed the medical charts of 44 patients, aged 6–12 years, who presented with food refusal and restrictive eating habits to a day treatment program at Rhode Island Hospital between 1999 and 2003. The treatment program takes a multidisciplinary team approach, collaborating closely with families and community providers.

At intake, families completed questionnaires about behavioral and family functioning, and quality of life. The mean age of study participants was 10 years, and more than half of the participants were female (67%). Most were white (82%), and 30% were on public insurance. The average length of stay in the program was 21 days.

The investigators divided the children into two groups. The 16 children who presented with body image distortion were called the early onset anorexia (EOA) group, while the 28 who presented with no body image distortion were called the atypical eating disorder (AED) group.

The two groups of children did not differ in terms of gender, insurance type, or program length of stay, but children in the AED group were about 2 years younger than their EOA counterparts (a mean of 9.7 years vs. 11.4 years, respectively).

All eight children from minority backgrounds were in the atypical eating disorder group; the children in the AED group were more likely to come from single-parent households than were those in the early onset anorexia group.

The two groups did not differ in terms of body mass index and most medical factors, but those in the EOA group were more likely to show cardiovascular compromise, exercise excessively, and have a family history of eating disorders, compared with the children in the AED group.

In addition, nearly 90% of the children in the EOA group had recent weight loss prior to starting the treatment program, compared with about 50% of those in the AED group. Of the children who had weight loss, the mean loss was 19.7 pounds in the EOA group, compared with a mean of 8.3 pounds in the AED group.

On the flip side, children in the AED group were more likely than their EOA counterparts to be described by their parents as having a history of picky eating, poor appetite, sensitivity to textures, slow eating, and difficulty swallowing.

Dr. Mehlenbeck said that the treatment implications differ for these two groups of children. “We would treat AED kids more behaviorally, similar to kids with anxiety and behavior disorders,” she said. “Treatment for kids with EOA would be similar to interventions for anorexia.”

Identifying children with food refusal problems early “may help quite a bit,” she added. “Collaboration is key. All of these kids need to be treated with a team format. So even if they're an outpatient, pediatricians should be working with a mental health worker who specializes in feeding or eating disorders, and a dietitian.”

Kate Johnson of the Montreal Bureau contributed to this report.

MONTREAL — Men who are overweight or obese have reduced serum testosterone levels, “which may help explain idiopathic oligospermia,” according to William E. Roudebush, Ph.D.

In his study of 90 men, “there was a substantial and significant reduction in testosterone of roughly 25%, regardless [of whether] they were overweight or obese,” said Dr. Roudebush, who presented his findings at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

“Rather than infertility therapy, maybe something as simple as weight reduction could work,” he said in an interview. “Medical literature states that as BMI increases, there's an increased conversion of testosterone to estradiol. Excess estradiol can cause a negative impact on testicular function. We know that [men are] going to have dysfunctional spermatogenesis based on that.”

In his observational study of 90 men with a mean age of 34, Dr. Roudebush and his associates at the Atlanta-based Reproductive Biology Associates compared patient BMI scores with their serum levels of testosterone, FSH, LH, and prolactin, as measured by chemiluminescence. Men were grouped by weight according to published BMI values: normal was defined as 20–24 kg/m

The mean values were 28.50 for BMI; 459 ng/dL for testosterone; 5.21 mU/mL for FSH; 3.69 U/L for LH, and 8.96 ng/mL for prolactin.

The analysis revealed an inverse relationship between BMI and serum testosterone levels. The mean serum testosterone level in the normal BMI group was 565 ng/dL, compared with almost 429 ng/dL in the overweight group and almost 416 ng/dL in the obese group.

No other reproductive serum markers had a significant relationship with BMI, but LH level approached significance. “We ran testosterone tests on everybody, but we did not have the approval to run the LH tests across the board, so we did not get enough values back to show statistical significance,” he said.

Beckman Coulter Inc. provided the testosterone test kits. Dr. Roudebush disclosed that he is a paid consultant for Beckman Coulter.

Kate Johnson of the Montreal Bureau contributed to this report.

MONTREAL — Men who are overweight or obese have reduced serum testosterone levels, “which may help explain idiopathic oligospermia,” according to William E. Roudebush, Ph.D.

In his study of 90 men, “there was a substantial and significant reduction in testosterone of roughly 25%, regardless [of whether] they were overweight or obese,” said Dr. Roudebush, who presented his findings at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

“Rather than infertility therapy, maybe something as simple as weight reduction could work,” he said in an interview. “Medical literature states that as BMI increases, there's an increased conversion of testosterone to estradiol. Excess estradiol can cause a negative impact on testicular function. We know that [men are] going to have dysfunctional spermatogenesis based on that.”

In his observational study of 90 men with a mean age of 34, Dr. Roudebush and his associates at the Atlanta-based Reproductive Biology Associates compared patient BMI scores with their serum levels of testosterone, FSH, LH, and prolactin, as measured by chemiluminescence. Men were grouped by weight according to published BMI values: normal was defined as 20–24 kg/m

The mean values were 28.50 for BMI; 459 ng/dL for testosterone; 5.21 mU/mL for FSH; 3.69 U/L for LH, and 8.96 ng/mL for prolactin.

The analysis revealed an inverse relationship between BMI and serum testosterone levels. The mean serum testosterone level in the normal BMI group was 565 ng/dL, compared with almost 429 ng/dL in the overweight group and almost 416 ng/dL in the obese group.

No other reproductive serum markers had a significant relationship with BMI, but LH level approached significance. “We ran testosterone tests on everybody, but we did not have the approval to run the LH tests across the board, so we did not get enough values back to show statistical significance,” he said.

Beckman Coulter Inc. provided the testosterone test kits. Dr. Roudebush disclosed that he is a paid consultant for Beckman Coulter.

Kate Johnson of the Montreal Bureau contributed to this report.

MONTREAL — Men who are overweight or obese have reduced serum testosterone levels, “which may help explain idiopathic oligospermia,” according to William E. Roudebush, Ph.D.

In his study of 90 men, “there was a substantial and significant reduction in testosterone of roughly 25%, regardless [of whether] they were overweight or obese,” said Dr. Roudebush, who presented his findings at the joint annual meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society.

“Rather than infertility therapy, maybe something as simple as weight reduction could work,” he said in an interview. “Medical literature states that as BMI increases, there's an increased conversion of testosterone to estradiol. Excess estradiol can cause a negative impact on testicular function. We know that [men are] going to have dysfunctional spermatogenesis based on that.”

In his observational study of 90 men with a mean age of 34, Dr. Roudebush and his associates at the Atlanta-based Reproductive Biology Associates compared patient BMI scores with their serum levels of testosterone, FSH, LH, and prolactin, as measured by chemiluminescence. Men were grouped by weight according to published BMI values: normal was defined as 20–24 kg/m

The mean values were 28.50 for BMI; 459 ng/dL for testosterone; 5.21 mU/mL for FSH; 3.69 U/L for LH, and 8.96 ng/mL for prolactin.

The analysis revealed an inverse relationship between BMI and serum testosterone levels. The mean serum testosterone level in the normal BMI group was 565 ng/dL, compared with almost 429 ng/dL in the overweight group and almost 416 ng/dL in the obese group.

No other reproductive serum markers had a significant relationship with BMI, but LH level approached significance. “We ran testosterone tests on everybody, but we did not have the approval to run the LH tests across the board, so we did not get enough values back to show statistical significance,” he said.

Beckman Coulter Inc. provided the testosterone test kits. Dr. Roudebush disclosed that he is a paid consultant for Beckman Coulter.

SAN DIEGO — Thermal balloon endometrial ablation is a safe and effective option for the treatment of women with idiopathic menorrhagia, results from a 3-year study of 330 women have shown.

“The procedure is simple, does not require additional training in operative hysterectomy, and compares favorably with other ablative techniques,” Stefanos Chandakas, M.D., Ph.D., reported at an international congress of the Society of Laparoendoscopic Surgeons. “These good results, however, need to be confirmed in a randomized, controlled trial.”

For the study, he and his associates used a 6-mm diameter Cavaterm Plus thermoablation system in 330 women with a mean age of 42 years.

All of the participants had experienced heavy menstrual bleeding, failed medical treatment for the condition, and otherwise would have required hysterectomy, endometrial laser ablation, or endometrial resection.

The outpatient procedures were performed from January 2001 to June 2004 at Princess Royal University Hospital and Farnborough Hospital, Orpington, England.

Contraindications included undiagnosed uterine bleeding, pregnancy or the desire to become pregnant, atypical endometrial cells, cervical length greater than 6 mm, gross uterine abnormalities that would result in an inappropriate balloon contact with the endometrium, a uterine cavity less than 4 cm or greater than 10 cm, uterine wall weakness, or ongoing infection.

No endometrial preparation was used. Each ablation lasted 10 minutes at a temperature of 78° C.

Follow-up occurred at intervals of 3, 6, 12, 24, and 36 months, for a mean of 22 months.

Nearly half of the participants (48%) were amenorrheic after 1 year, while the rates of amenorrhea were 39% and 38% after 2 and 3 years, respectively. (See chart.)

The majority of women (83%) reported a reduction in dysmenorrhea and premenstrual symptoms at 1 year, “which is a recognized and consistent finding following endometrial destructive procedures,” said Dr. Chandakas of the minimal access unit in the department of obstetrics and gynecology at Princess Royal.

At 3 years, 73% of women reported a reduction in dysmenorrhea and premenstrual symptoms.

No balloons failed, and no major complications were noted.

Dr. Chandakas credited the success of the procedure in large measure to the Cavaterm Plus silicone balloon, which is formed to adapt to the uterine cavity. “The adjustable balloon length fits every uterus and protects the cervix from burns,” he said.

Dr. Chandakas disclosed that he has no financial interest in Wallsten Medical, the Swiss manufacturer of Cavaterm Plus.

SAN DIEGO — Thermal balloon endometrial ablation is a safe and effective option for the treatment of women with idiopathic menorrhagia, results from a 3-year study of 330 women have shown.

“The procedure is simple, does not require additional training in operative hysterectomy, and compares favorably with other ablative techniques,” Stefanos Chandakas, M.D., Ph.D., reported at an international congress of the Society of Laparoendoscopic Surgeons. “These good results, however, need to be confirmed in a randomized, controlled trial.”

For the study, he and his associates used a 6-mm diameter Cavaterm Plus thermoablation system in 330 women with a mean age of 42 years.

All of the participants had experienced heavy menstrual bleeding, failed medical treatment for the condition, and otherwise would have required hysterectomy, endometrial laser ablation, or endometrial resection.

The outpatient procedures were performed from January 2001 to June 2004 at Princess Royal University Hospital and Farnborough Hospital, Orpington, England.

Contraindications included undiagnosed uterine bleeding, pregnancy or the desire to become pregnant, atypical endometrial cells, cervical length greater than 6 mm, gross uterine abnormalities that would result in an inappropriate balloon contact with the endometrium, a uterine cavity less than 4 cm or greater than 10 cm, uterine wall weakness, or ongoing infection.

No endometrial preparation was used. Each ablation lasted 10 minutes at a temperature of 78° C.

Follow-up occurred at intervals of 3, 6, 12, 24, and 36 months, for a mean of 22 months.

Nearly half of the participants (48%) were amenorrheic after 1 year, while the rates of amenorrhea were 39% and 38% after 2 and 3 years, respectively. (See chart.)

The majority of women (83%) reported a reduction in dysmenorrhea and premenstrual symptoms at 1 year, “which is a recognized and consistent finding following endometrial destructive procedures,” said Dr. Chandakas of the minimal access unit in the department of obstetrics and gynecology at Princess Royal.

At 3 years, 73% of women reported a reduction in dysmenorrhea and premenstrual symptoms.

No balloons failed, and no major complications were noted.

Dr. Chandakas credited the success of the procedure in large measure to the Cavaterm Plus silicone balloon, which is formed to adapt to the uterine cavity. “The adjustable balloon length fits every uterus and protects the cervix from burns,” he said.

Dr. Chandakas disclosed that he has no financial interest in Wallsten Medical, the Swiss manufacturer of Cavaterm Plus.

SAN DIEGO — Thermal balloon endometrial ablation is a safe and effective option for the treatment of women with idiopathic menorrhagia, results from a 3-year study of 330 women have shown.

“The procedure is simple, does not require additional training in operative hysterectomy, and compares favorably with other ablative techniques,” Stefanos Chandakas, M.D., Ph.D., reported at an international congress of the Society of Laparoendoscopic Surgeons. “These good results, however, need to be confirmed in a randomized, controlled trial.”

For the study, he and his associates used a 6-mm diameter Cavaterm Plus thermoablation system in 330 women with a mean age of 42 years.

All of the participants had experienced heavy menstrual bleeding, failed medical treatment for the condition, and otherwise would have required hysterectomy, endometrial laser ablation, or endometrial resection.

The outpatient procedures were performed from January 2001 to June 2004 at Princess Royal University Hospital and Farnborough Hospital, Orpington, England.

Contraindications included undiagnosed uterine bleeding, pregnancy or the desire to become pregnant, atypical endometrial cells, cervical length greater than 6 mm, gross uterine abnormalities that would result in an inappropriate balloon contact with the endometrium, a uterine cavity less than 4 cm or greater than 10 cm, uterine wall weakness, or ongoing infection.

No endometrial preparation was used. Each ablation lasted 10 minutes at a temperature of 78° C.

Follow-up occurred at intervals of 3, 6, 12, 24, and 36 months, for a mean of 22 months.

Nearly half of the participants (48%) were amenorrheic after 1 year, while the rates of amenorrhea were 39% and 38% after 2 and 3 years, respectively. (See chart.)

The majority of women (83%) reported a reduction in dysmenorrhea and premenstrual symptoms at 1 year, “which is a recognized and consistent finding following endometrial destructive procedures,” said Dr. Chandakas of the minimal access unit in the department of obstetrics and gynecology at Princess Royal.

At 3 years, 73% of women reported a reduction in dysmenorrhea and premenstrual symptoms.

No balloons failed, and no major complications were noted.

Dr. Chandakas credited the success of the procedure in large measure to the Cavaterm Plus silicone balloon, which is formed to adapt to the uterine cavity. “The adjustable balloon length fits every uterus and protects the cervix from burns,” he said.

Dr. Chandakas disclosed that he has no financial interest in Wallsten Medical, the Swiss manufacturer of Cavaterm Plus.

SAN DIEGO — When it comes to helping adolescents with Down syndrome and other cognitive disabilities transition to adult services, the earlier the better, William I. Cohen, M.D., advised at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Such an approach “makes perfect sense at one level, and at another level it's very hard to do, because some families don't start looking ahead early enough,” said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

“When you receive a diagnosis of a disorder that is associated with cognitive disabilities, the crushing blow is knowing that forever and ever your child is going to be different. And [parents] begin to think about all of these things in the future. That is what I think terrifies them.”

He pointed out that needs of the adolescent and the family may exist on different levels. For example, the adolescent may want to live independently or in a group home when he or she turns 18, while the family may feel obligated to care for the child at home for the foreseeable future.

“Identify key individuals who can assist in this process and start with the end in mind,” he recommended. “Decide where you want to end up so you can begin early on” heading toward that goal as opposed to it all of a sudden springing up on you: All of a sudden the child is 13–18 years of age with all of these needs.

Dr. Cohen called the transition to adult services “a journey, not a destination. It is a continuous and dynamic process and is variable depending on the individual, family, community, and state in which they live, and the financial and emotional resources [of the family] as well.”

He and his associate, Sheila A. Cannon, offered the following tips on making transition planning run as smoothly as possible:

▸ Identify the educational needs. By the time the child turns 14 years of age, families should identify a course of study that matches the teen's interests and goals, and consider the need for supplemental services such as occupational therapy, speech/language therapy, and physical therapy. Then they should identify community resources and interagency responsibilities.

By law, all people with cognitive disabilities qualify for school services through age 21. Some remain in high school past age 18 to receive such services, but others choose to graduate with their peers and move on to other educational programs in the community that prepare them for employment, money management, and independent living skills.

Ms. Cannon's daughter, who has Down syndrome, was adamant about not going back to high school after graduating. “She took a certificate and opted for a program that is sponsored by another organization and provides vocational training on a college campus,” said Ms. Cannon, coordinator at the Down Syndrome Center of Western Pennsylvania. “So she is with her same-age peers” and the school district provides transportation.

She advises adolescents with cognitive disabilities to undergo a vocational assessment at their local offices of vocational rehabilitation. That way, the local agencies have them on their radar and may be able to match an employment need based on their interests and skill levels.

“The transition plan should encourage students to take courses or have some type of planning in nutrition or fitness,” Ms. Cannon said, adding that her daughter attends a behavioral health class at a local college once a week.

Courses that address sexuality and self-esteem also are important. “It's important to have those options available for kids to learn about appropriate social distance and appropriate social interaction,” she said.

▸ Help the family identify an appropriate primary care physician. In the shift from pediatrician/family physician to internist or another physician, the real dilemma for patients and their families is the loss of their medical home, Dr. Cohen said.

“Families will ask, 'Who can be my child's primary care physician?' We ask the parents, 'Could it be your own physician, or someone you have a relationship with and would be willing to take on that role?'”

A key quality for the new physician is a willingness to partner with the family and other clinicians on behalf of the adolescent. “Even if they don't know much about the particular condition, their willingness to partner with the family and use available resources is most important,” Dr. Cohen said.

The new physician must be able to address chronic health problems, understand specific medical vulnerabilities, manage acute illness, and identify adult specialists.

If all else fails in the search for a new physician, have the family call its health insurer or managed care organization, Ms. Cannon said. “Often they have a special needs case manager that the family can connect with. They can give them a list of physicians who take that insurance.”

Dr. Cohen noted that young adults with Down syndrome who show signs of depression are often misinterpreted as having early Alzheimer's disease.

“We've known for quite some time that individuals with cognitive disabilities get depressed the same as other individuals for the same kinds of things, such as siblings moving on, loss of a caregiver or a roommate, or death of a parent,” he explained.

“We have seen a number of young adults who have developed some significant reactions to the loss of support, in terms of depression. They find themselves foundering.”

Obsessive-compulsive disorder also may emerge as a coping mechanism.

▸ Talk about living arrangements. Ms. Cannon pointed out that most opportunities for independent living or community living arrangements for young adults with cognitive disabilities are handled through state offices of mental retardation.

In Pennsylvania, for example, candidates for housing must prove they have a cognitive disability before the age of 21. Then they're put on a waiting list.

“If families don't do a reassessment of need every year, they can be dropped from the system,” Ms. Cannon cautioned.

She called the transition to adult services “as stressful and as unknown as when parents got the initial diagnosis for the child. It's really important to do educational planning and health care planning, to do as much as we can to help these families know what's really out there.”

For resources on transition planning, visit the “tools and solutions” section of the Healthy and Ready to Work National Center, a federally funded clearinghouse of information, at www.hrtw.org

SAN DIEGO — When it comes to helping adolescents with Down syndrome and other cognitive disabilities transition to adult services, the earlier the better, William I. Cohen, M.D., advised at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Such an approach “makes perfect sense at one level, and at another level it's very hard to do, because some families don't start looking ahead early enough,” said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

“When you receive a diagnosis of a disorder that is associated with cognitive disabilities, the crushing blow is knowing that forever and ever your child is going to be different. And [parents] begin to think about all of these things in the future. That is what I think terrifies them.”

He pointed out that needs of the adolescent and the family may exist on different levels. For example, the adolescent may want to live independently or in a group home when he or she turns 18, while the family may feel obligated to care for the child at home for the foreseeable future.

“Identify key individuals who can assist in this process and start with the end in mind,” he recommended. “Decide where you want to end up so you can begin early on” heading toward that goal as opposed to it all of a sudden springing up on you: All of a sudden the child is 13–18 years of age with all of these needs.

Dr. Cohen called the transition to adult services “a journey, not a destination. It is a continuous and dynamic process and is variable depending on the individual, family, community, and state in which they live, and the financial and emotional resources [of the family] as well.”

He and his associate, Sheila A. Cannon, offered the following tips on making transition planning run as smoothly as possible:

▸ Identify the educational needs. By the time the child turns 14 years of age, families should identify a course of study that matches the teen's interests and goals, and consider the need for supplemental services such as occupational therapy, speech/language therapy, and physical therapy. Then they should identify community resources and interagency responsibilities.

By law, all people with cognitive disabilities qualify for school services through age 21. Some remain in high school past age 18 to receive such services, but others choose to graduate with their peers and move on to other educational programs in the community that prepare them for employment, money management, and independent living skills.

Ms. Cannon's daughter, who has Down syndrome, was adamant about not going back to high school after graduating. “She took a certificate and opted for a program that is sponsored by another organization and provides vocational training on a college campus,” said Ms. Cannon, coordinator at the Down Syndrome Center of Western Pennsylvania. “So she is with her same-age peers” and the school district provides transportation.

She advises adolescents with cognitive disabilities to undergo a vocational assessment at their local offices of vocational rehabilitation. That way, the local agencies have them on their radar and may be able to match an employment need based on their interests and skill levels.

“The transition plan should encourage students to take courses or have some type of planning in nutrition or fitness,” Ms. Cannon said, adding that her daughter attends a behavioral health class at a local college once a week.

Courses that address sexuality and self-esteem also are important. “It's important to have those options available for kids to learn about appropriate social distance and appropriate social interaction,” she said.

▸ Help the family identify an appropriate primary care physician. In the shift from pediatrician/family physician to internist or another physician, the real dilemma for patients and their families is the loss of their medical home, Dr. Cohen said.

“Families will ask, 'Who can be my child's primary care physician?' We ask the parents, 'Could it be your own physician, or someone you have a relationship with and would be willing to take on that role?'”

A key quality for the new physician is a willingness to partner with the family and other clinicians on behalf of the adolescent. “Even if they don't know much about the particular condition, their willingness to partner with the family and use available resources is most important,” Dr. Cohen said.

The new physician must be able to address chronic health problems, understand specific medical vulnerabilities, manage acute illness, and identify adult specialists.

If all else fails in the search for a new physician, have the family call its health insurer or managed care organization, Ms. Cannon said. “Often they have a special needs case manager that the family can connect with. They can give them a list of physicians who take that insurance.”

Dr. Cohen noted that young adults with Down syndrome who show signs of depression are often misinterpreted as having early Alzheimer's disease.

“We've known for quite some time that individuals with cognitive disabilities get depressed the same as other individuals for the same kinds of things, such as siblings moving on, loss of a caregiver or a roommate, or death of a parent,” he explained.

“We have seen a number of young adults who have developed some significant reactions to the loss of support, in terms of depression. They find themselves foundering.”

Obsessive-compulsive disorder also may emerge as a coping mechanism.

▸ Talk about living arrangements. Ms. Cannon pointed out that most opportunities for independent living or community living arrangements for young adults with cognitive disabilities are handled through state offices of mental retardation.

In Pennsylvania, for example, candidates for housing must prove they have a cognitive disability before the age of 21. Then they're put on a waiting list.

“If families don't do a reassessment of need every year, they can be dropped from the system,” Ms. Cannon cautioned.

She called the transition to adult services “as stressful and as unknown as when parents got the initial diagnosis for the child. It's really important to do educational planning and health care planning, to do as much as we can to help these families know what's really out there.”

For resources on transition planning, visit the “tools and solutions” section of the Healthy and Ready to Work National Center, a federally funded clearinghouse of information, at www.hrtw.org

SAN DIEGO — When it comes to helping adolescents with Down syndrome and other cognitive disabilities transition to adult services, the earlier the better, William I. Cohen, M.D., advised at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Such an approach “makes perfect sense at one level, and at another level it's very hard to do, because some families don't start looking ahead early enough,” said Dr. Cohen, director of the Down Syndrome Center of Western Pennsylvania, Pittsburgh.

“When you receive a diagnosis of a disorder that is associated with cognitive disabilities, the crushing blow is knowing that forever and ever your child is going to be different. And [parents] begin to think about all of these things in the future. That is what I think terrifies them.”

He pointed out that needs of the adolescent and the family may exist on different levels. For example, the adolescent may want to live independently or in a group home when he or she turns 18, while the family may feel obligated to care for the child at home for the foreseeable future.

“Identify key individuals who can assist in this process and start with the end in mind,” he recommended. “Decide where you want to end up so you can begin early on” heading toward that goal as opposed to it all of a sudden springing up on you: All of a sudden the child is 13–18 years of age with all of these needs.

Dr. Cohen called the transition to adult services “a journey, not a destination. It is a continuous and dynamic process and is variable depending on the individual, family, community, and state in which they live, and the financial and emotional resources [of the family] as well.”

He and his associate, Sheila A. Cannon, offered the following tips on making transition planning run as smoothly as possible:

▸ Identify the educational needs. By the time the child turns 14 years of age, families should identify a course of study that matches the teen's interests and goals, and consider the need for supplemental services such as occupational therapy, speech/language therapy, and physical therapy. Then they should identify community resources and interagency responsibilities.

By law, all people with cognitive disabilities qualify for school services through age 21. Some remain in high school past age 18 to receive such services, but others choose to graduate with their peers and move on to other educational programs in the community that prepare them for employment, money management, and independent living skills.

Ms. Cannon's daughter, who has Down syndrome, was adamant about not going back to high school after graduating. “She took a certificate and opted for a program that is sponsored by another organization and provides vocational training on a college campus,” said Ms. Cannon, coordinator at the Down Syndrome Center of Western Pennsylvania. “So she is with her same-age peers” and the school district provides transportation.

She advises adolescents with cognitive disabilities to undergo a vocational assessment at their local offices of vocational rehabilitation. That way, the local agencies have them on their radar and may be able to match an employment need based on their interests and skill levels.

“The transition plan should encourage students to take courses or have some type of planning in nutrition or fitness,” Ms. Cannon said, adding that her daughter attends a behavioral health class at a local college once a week.

Courses that address sexuality and self-esteem also are important. “It's important to have those options available for kids to learn about appropriate social distance and appropriate social interaction,” she said.

▸ Help the family identify an appropriate primary care physician. In the shift from pediatrician/family physician to internist or another physician, the real dilemma for patients and their families is the loss of their medical home, Dr. Cohen said.

“Families will ask, 'Who can be my child's primary care physician?' We ask the parents, 'Could it be your own physician, or someone you have a relationship with and would be willing to take on that role?'”

A key quality for the new physician is a willingness to partner with the family and other clinicians on behalf of the adolescent. “Even if they don't know much about the particular condition, their willingness to partner with the family and use available resources is most important,” Dr. Cohen said.

The new physician must be able to address chronic health problems, understand specific medical vulnerabilities, manage acute illness, and identify adult specialists.

If all else fails in the search for a new physician, have the family call its health insurer or managed care organization, Ms. Cannon said. “Often they have a special needs case manager that the family can connect with. They can give them a list of physicians who take that insurance.”

Dr. Cohen noted that young adults with Down syndrome who show signs of depression are often misinterpreted as having early Alzheimer's disease.

“We've known for quite some time that individuals with cognitive disabilities get depressed the same as other individuals for the same kinds of things, such as siblings moving on, loss of a caregiver or a roommate, or death of a parent,” he explained.

“We have seen a number of young adults who have developed some significant reactions to the loss of support, in terms of depression. They find themselves foundering.”

Obsessive-compulsive disorder also may emerge as a coping mechanism.

▸ Talk about living arrangements. Ms. Cannon pointed out that most opportunities for independent living or community living arrangements for young adults with cognitive disabilities are handled through state offices of mental retardation.

In Pennsylvania, for example, candidates for housing must prove they have a cognitive disability before the age of 21. Then they're put on a waiting list.

“If families don't do a reassessment of need every year, they can be dropped from the system,” Ms. Cannon cautioned.

She called the transition to adult services “as stressful and as unknown as when parents got the initial diagnosis for the child. It's really important to do educational planning and health care planning, to do as much as we can to help these families know what's really out there.”

For resources on transition planning, visit the “tools and solutions” section of the Healthy and Ready to Work National Center, a federally funded clearinghouse of information, at www.hrtw.org

YOSEMITE, CALIF. — The best laboratory evidence of puberty is a test for luteinizing hormone and follicle-stimulating hormone done by immunochemiluminometric assay, Stephen M. Rosenthal, M.D., said at a pediatric conference sponsored by Symposia Medicus.

Two labs that run the tests are Esoterix Inc. and Quest Diagnostics Inc., said Dr. Rosenthal, professor of pediatrics at the University of California, San Francisco.

“If you ever order tests for LH and FSH, it's very important that you order them by immunochemiluminometric assay (ICMA), because [the tests] are able to distinguish between someone who's prepubertal and the different Tanner stages,” he said.

If you get results that are difficult to interpret, Dr. Rosenthal recommended doing a GnRH stimulation test, which is also called a luteinizing hormone releasing factor (LRF) stimulation test. This involves giving a synthetic bolus of GnRH and then measuring the patient's levels of LH, FSH, and either estradiol or testosterone.

Dr. Rosenthal noted that there have been availability problems with GnRH. If GnRH is not available, a similar test can be done with leuprolide acetate, a GnRH agonist. Guidelines for carrying out the latter test are described in the following reference: J. Clin. Endocrinol. Metab. 1994;78:30–5.

“If you give an injection of synthetic GnRH [or agonist] to somebody who's in puberty, their own pituitary gland has been primed by their own GnRH; so when you give it, you're going to see a vigorous rise in LH,” he explained.

The differential diagnosis of delayed puberty is defined clinically as a girl who has no evidence of breast development by age 13 years or a boy who has no evidence of testicular enlargement by age 14 years. The following are general possibilities in this differential diagnosis:

▸ Constitutional delay in growth. Most children seen for concerns about delayed puberty will fit this category.

“This is one of those interesting scenarios where it appears that people not only grow more slowly and reach puberty more slowly, it's like there's something in their biological clock that makes them age more slowly,” Dr. Rosenthal noted. “They ultimately reach a normal adult height and full pubertal development; it just takes them longer to get there. This often runs in families. Is it possible that these kids actually age more slowly as they grow older, even as adults?” he asked. “Is there something to be learned here to give us some insight? We don't know the answer to that yet because there are so many variables as we get older that affect longevity.”

▸ Hypogonadotropic hypogonadism. In this condition, the defect is located in the hypothalamus or in the pituitary gland. The cause could be Kallmann syndrome or could be associated with other conditions including cleft palate; congenital deafness; the X-linked form of congenital adrenal hypoplasia; Prader-Willi syndrome; Laurence-Moon-Biedl syndrome; central nervous system disease; and a variety of other conditions such as hypothyroidism, poorly controlled diabetes, and anorexia nervosa.

▸ Hypergonadotropic hypogonadism. In this condition, the defect is in the testes or ovaries. Potential causes include Klinefelter's syndrome and its variants; anorchia; cryptorchidism; XY gonadal dysgenesis; Noonan's syndrome; Turner's syndrome and its variants; and XX gonadal dysgenesis.

YOSEMITE, CALIF. — The best laboratory evidence of puberty is a test for luteinizing hormone and follicle-stimulating hormone done by immunochemiluminometric assay, Stephen M. Rosenthal, M.D., said at a pediatric conference sponsored by Symposia Medicus.

Two labs that run the tests are Esoterix Inc. and Quest Diagnostics Inc., said Dr. Rosenthal, professor of pediatrics at the University of California, San Francisco.

“If you ever order tests for LH and FSH, it's very important that you order them by immunochemiluminometric assay (ICMA), because [the tests] are able to distinguish between someone who's prepubertal and the different Tanner stages,” he said.

If you get results that are difficult to interpret, Dr. Rosenthal recommended doing a GnRH stimulation test, which is also called a luteinizing hormone releasing factor (LRF) stimulation test. This involves giving a synthetic bolus of GnRH and then measuring the patient's levels of LH, FSH, and either estradiol or testosterone.

Dr. Rosenthal noted that there have been availability problems with GnRH. If GnRH is not available, a similar test can be done with leuprolide acetate, a GnRH agonist. Guidelines for carrying out the latter test are described in the following reference: J. Clin. Endocrinol. Metab. 1994;78:30–5.

“If you give an injection of synthetic GnRH [or agonist] to somebody who's in puberty, their own pituitary gland has been primed by their own GnRH; so when you give it, you're going to see a vigorous rise in LH,” he explained.

The differential diagnosis of delayed puberty is defined clinically as a girl who has no evidence of breast development by age 13 years or a boy who has no evidence of testicular enlargement by age 14 years. The following are general possibilities in this differential diagnosis:

▸ Constitutional delay in growth. Most children seen for concerns about delayed puberty will fit this category.

“This is one of those interesting scenarios where it appears that people not only grow more slowly and reach puberty more slowly, it's like there's something in their biological clock that makes them age more slowly,” Dr. Rosenthal noted. “They ultimately reach a normal adult height and full pubertal development; it just takes them longer to get there. This often runs in families. Is it possible that these kids actually age more slowly as they grow older, even as adults?” he asked. “Is there something to be learned here to give us some insight? We don't know the answer to that yet because there are so many variables as we get older that affect longevity.”

▸ Hypogonadotropic hypogonadism. In this condition, the defect is located in the hypothalamus or in the pituitary gland. The cause could be Kallmann syndrome or could be associated with other conditions including cleft palate; congenital deafness; the X-linked form of congenital adrenal hypoplasia; Prader-Willi syndrome; Laurence-Moon-Biedl syndrome; central nervous system disease; and a variety of other conditions such as hypothyroidism, poorly controlled diabetes, and anorexia nervosa.

▸ Hypergonadotropic hypogonadism. In this condition, the defect is in the testes or ovaries. Potential causes include Klinefelter's syndrome and its variants; anorchia; cryptorchidism; XY gonadal dysgenesis; Noonan's syndrome; Turner's syndrome and its variants; and XX gonadal dysgenesis.

YOSEMITE, CALIF. — The best laboratory evidence of puberty is a test for luteinizing hormone and follicle-stimulating hormone done by immunochemiluminometric assay, Stephen M. Rosenthal, M.D., said at a pediatric conference sponsored by Symposia Medicus.

Two labs that run the tests are Esoterix Inc. and Quest Diagnostics Inc., said Dr. Rosenthal, professor of pediatrics at the University of California, San Francisco.

“If you ever order tests for LH and FSH, it's very important that you order them by immunochemiluminometric assay (ICMA), because [the tests] are able to distinguish between someone who's prepubertal and the different Tanner stages,” he said.

If you get results that are difficult to interpret, Dr. Rosenthal recommended doing a GnRH stimulation test, which is also called a luteinizing hormone releasing factor (LRF) stimulation test. This involves giving a synthetic bolus of GnRH and then measuring the patient's levels of LH, FSH, and either estradiol or testosterone.

Dr. Rosenthal noted that there have been availability problems with GnRH. If GnRH is not available, a similar test can be done with leuprolide acetate, a GnRH agonist. Guidelines for carrying out the latter test are described in the following reference: J. Clin. Endocrinol. Metab. 1994;78:30–5.

“If you give an injection of synthetic GnRH [or agonist] to somebody who's in puberty, their own pituitary gland has been primed by their own GnRH; so when you give it, you're going to see a vigorous rise in LH,” he explained.

The differential diagnosis of delayed puberty is defined clinically as a girl who has no evidence of breast development by age 13 years or a boy who has no evidence of testicular enlargement by age 14 years. The following are general possibilities in this differential diagnosis:

▸ Constitutional delay in growth. Most children seen for concerns about delayed puberty will fit this category.

“This is one of those interesting scenarios where it appears that people not only grow more slowly and reach puberty more slowly, it's like there's something in their biological clock that makes them age more slowly,” Dr. Rosenthal noted. “They ultimately reach a normal adult height and full pubertal development; it just takes them longer to get there. This often runs in families. Is it possible that these kids actually age more slowly as they grow older, even as adults?” he asked. “Is there something to be learned here to give us some insight? We don't know the answer to that yet because there are so many variables as we get older that affect longevity.”

▸ Hypogonadotropic hypogonadism. In this condition, the defect is located in the hypothalamus or in the pituitary gland. The cause could be Kallmann syndrome or could be associated with other conditions including cleft palate; congenital deafness; the X-linked form of congenital adrenal hypoplasia; Prader-Willi syndrome; Laurence-Moon-Biedl syndrome; central nervous system disease; and a variety of other conditions such as hypothyroidism, poorly controlled diabetes, and anorexia nervosa.

▸ Hypergonadotropic hypogonadism. In this condition, the defect is in the testes or ovaries. Potential causes include Klinefelter's syndrome and its variants; anorchia; cryptorchidism; XY gonadal dysgenesis; Noonan's syndrome; Turner's syndrome and its variants; and XX gonadal dysgenesis.