Kerri Wachter

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

ORLANDO — The difference between acceptable and unacceptable results for a blepharoplasty can be as little as a millimeter, so small improvements in anesthestic control and precision can have a large effect, Dr. Marc Cohen said at the annual meeting of the American Academy of Cosmetic Surgery.

"A tolerance of 1 mm or less is a very high standard to live up to," said Dr. Cohen, a cosmetic surgeon at Wills Eye Hospital in Philadelphia. "The simple truth is that you cannot make the type of intraoperative decisions that give you that type of precision unless the surgery at each step is performed under tremendous control."

Dr. Cohen offered tips that can make a big difference in results when it comes to maintaining patient comfort and giving the anesthetic block. "Every surgery has a weakest link in terms of surgical control. … Interestingly, the weakest links that I've found—in terms of bleeding and bruising—tend to be the least technically difficult parts of the surgery," he said.

Keeping the patient comfortable during surgery can have the biggest impact on the quality of the end results. Patient pain and anxiety cause bleeding. The anesthesiologists that he works with understand that he wants patients as sedate as is medically safe throughout the entire procedure.

There are several tricks that can be used to perform a block without bruising. "All of us have had a case where we've given a block and developed a big bruise. The rest of the operation is more difficult," Dr. Cohen said.

He uses Xylocaine (lidocaine) with epinephrine and hyaluronidase injected in the smallest possible needle (32 gauge). The needle is injected at one site laterally. The injection should be superficial to avoid the highly vascular orbicularis.

"Once the needle is in place, it's not moved and a 2- to 3-cc bolus injection is given," Dr. Cohen explained. Remove the needle and massage the bolus immediately.

A transconjunctival block poses more of a bruising problem because the conjunctiva is highly vascular. Dr. Cohen's trick is to constrict the blood vessels before giving the block by using a drop of 2.5% phenylephrine.

There are, however, patients for whom it just is not prudent to have heavy sedation. "You're at a significant disadvantage with these people because they are much more likely to bleed and bruise during surgery," said Dr. Cohen. This is especially true for performing a block. "We go to great lengths to ensure that the block is painless so there is no bruising."

For these patients, Dr. Cohen uses a syringe device called the Wand (Milestone Scientific), which has a microprocessor. The microprocessor controls the rate of flow so there is a constant pressure that is below the pain threshold. When using this device, Dr. Cohen uses the same technique as for a standard block. He reported no conflict of interest with the device.

The needle is not moved during the injection of a 2- to 3-cc bolus. After the needle is removed, the bolus is massaged immediately. Courtesy Dr. Marc Cohen

SAN JUAN, P.R. — Sleep disorders become more common with increasing age, but effective behavioral and pharmacologic therapies are available, sleep experts said at the annual meeting of the American Association for Geriatric Psychiatry.

“Most older adults are not being treated for their insomnia, and most older adults won't get a diagnosis of insomnia,” despite the high prevalence of the disorder among older individuals, said Dr. Phyllis C. Zee, medical director of the Sleep Disorders Center at Northwestern Memorial Hospital in Chicago.

There are several age-related changes in sleep architecture. The number of awakenings during sleep time increases, especially in early morning. The amount of light sleep is increased and the amount of deep sleep is decreased. There also is less REM sleep, said Dr. Zee, who also serves as a professor of neurology, neurobiology, and physiology at Northwestern University, Chicago.

Two major mechanisms regulate sleep in humans: the homeostatic drive and the circadian drive. Control of the circadian system resides in the suprachiasmatic nucleus, which provides timing information for physiologic, hormonal, and behavioral rhythms.

Several changes in circadian sleep rhythms come with age. The amplitude of circadian rhythms decreases, while the variability of circadian rhythms increases. “There's also a very noticeable advance in [the] phase of circadian rhythms,” Dr. Zee said. Severe disruptions of the sleep/wake cycle often occur among older adults with dementia and in those in nursing homes.

The homeostatic drive for sleep depends on accumulating enough hours of wakefulness to trigger sleep, and this drive is reset during sleep. It's thought that the homeostatic drive is regulated by the ventrolateral preoptic area of the hypothalamus.

It's important to understand these sleep mechanisms when treating sleep disorders. “There is not a thing you can do to make yourself go to sleep. … What you can do is arrange the circumstances and timing of your wakefulness in a way that makes the involuntary process of sleep more likely,” said Dr. Daniel J. Buysse, medical director of the sleep evaluation center at the Western Psychiatric Institute and Clinic of the University of Pittsburgh

To understand the patient's sleep habits, behavioral therapists start by asking about average time in bed, average rise time, total time in bed, time to fall asleep, amount of wakefulness during the night, and total wake time. Using this information, they calculate the amount of total sleep (total time in bed minus total wake time). For most individuals with insomnia, there is a discrepancy between the amount of sleep that they get and the amount of time they spend in bed, said Dr. Buysse, also a professor of psychiatry at the University of Pittsburgh.

Dr. Buysse and his colleagues have tested the effect of these changes in sleep behavior on sleep quality in a small study of 13 patients who made these changes, compared with 12 subjects who received basic sleep information.

Those in the active treatment group showed a significant improvement in sleep quality, while those in the control group showed no change.

In addition, those in the active treatment group showed improvement in sleep latency—how long it takes to fall asleep—and waking after sleep onset, while controls did not.

Pharmacologic management of acute and chronic insomnia includes benzodiazepine receptor agonists, melatonin, melatonin receptor agonists, and antidepressants.

In 2005, a National Institutes of Health state-of-the-science panel noted that hypnotics are efficacious in the short-term treatment of insomnia. However, with the exception of eszopiclone, the benefits have not been studied for long-term use.

Zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta)—benzodiazepine receptor agonists—are all indicated for the treatment of insomnia. “These drugs differ [from benzodiazepines] mainly in terms of their pharmacokinetics,” said Dr. Buysse. Otherwise, these drugs are quite similar to benzodiazepines. One note of caution, however: Benzodiazepines and related drugs have been shown to be a risk factor for falls.

Ramelteon, a melatonin receptor agonist, “takes advantage of the circadian system that secretes melatonin at night,” Dr. Buysse said. Ramelteon is short acting and has an active metabolite. Caution should be used with this drug when prescribed for patients also taking fluvoxamine, which inhibits some of the enzymes that degrade ramelteon.

Ramelteon has been shown to reduce sleep latency and increase total sleep time in younger and older adults. The drug appears to be less effective on wakefulness after sleep onset.

No evidence-based standards of practice or treatment algorithms exist for treating insomnia in older adults, “but I think that it makes sense to always use behavioral approaches before, or in combination with, medication,” Dr. Buysse said.

SAN JUAN, P.R. — Sleep disorders become more common with increasing age, but effective behavioral and pharmacologic therapies are available, sleep experts said at the annual meeting of the American Association for Geriatric Psychiatry.

“Most older adults are not being treated for their insomnia, and most older adults won't get a diagnosis of insomnia,” despite the high prevalence of the disorder among older individuals, said Dr. Phyllis C. Zee, medical director of the Sleep Disorders Center at Northwestern Memorial Hospital in Chicago.

There are several age-related changes in sleep architecture. The number of awakenings during sleep time increases, especially in early morning. The amount of light sleep is increased and the amount of deep sleep is decreased. There also is less REM sleep, said Dr. Zee, who also serves as a professor of neurology, neurobiology, and physiology at Northwestern University, Chicago.

Two major mechanisms regulate sleep in humans: the homeostatic drive and the circadian drive. Control of the circadian system resides in the suprachiasmatic nucleus, which provides timing information for physiologic, hormonal, and behavioral rhythms.

Several changes in circadian sleep rhythms come with age. The amplitude of circadian rhythms decreases, while the variability of circadian rhythms increases. “There's also a very noticeable advance in [the] phase of circadian rhythms,” Dr. Zee said. Severe disruptions of the sleep/wake cycle often occur among older adults with dementia and in those in nursing homes.

The homeostatic drive for sleep depends on accumulating enough hours of wakefulness to trigger sleep, and this drive is reset during sleep. It's thought that the homeostatic drive is regulated by the ventrolateral preoptic area of the hypothalamus.

It's important to understand these sleep mechanisms when treating sleep disorders. “There is not a thing you can do to make yourself go to sleep. … What you can do is arrange the circumstances and timing of your wakefulness in a way that makes the involuntary process of sleep more likely,” said Dr. Daniel J. Buysse, medical director of the sleep evaluation center at the Western Psychiatric Institute and Clinic of the University of Pittsburgh

To understand the patient's sleep habits, behavioral therapists start by asking about average time in bed, average rise time, total time in bed, time to fall asleep, amount of wakefulness during the night, and total wake time. Using this information, they calculate the amount of total sleep (total time in bed minus total wake time). For most individuals with insomnia, there is a discrepancy between the amount of sleep that they get and the amount of time they spend in bed, said Dr. Buysse, also a professor of psychiatry at the University of Pittsburgh.

Dr. Buysse and his colleagues have tested the effect of these changes in sleep behavior on sleep quality in a small study of 13 patients who made these changes, compared with 12 subjects who received basic sleep information.

Those in the active treatment group showed a significant improvement in sleep quality, while those in the control group showed no change.

In addition, those in the active treatment group showed improvement in sleep latency—how long it takes to fall asleep—and waking after sleep onset, while controls did not.

Pharmacologic management of acute and chronic insomnia includes benzodiazepine receptor agonists, melatonin, melatonin receptor agonists, and antidepressants.

In 2005, a National Institutes of Health state-of-the-science panel noted that hypnotics are efficacious in the short-term treatment of insomnia. However, with the exception of eszopiclone, the benefits have not been studied for long-term use.

Zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta)—benzodiazepine receptor agonists—are all indicated for the treatment of insomnia. “These drugs differ [from benzodiazepines] mainly in terms of their pharmacokinetics,” said Dr. Buysse. Otherwise, these drugs are quite similar to benzodiazepines. One note of caution, however: Benzodiazepines and related drugs have been shown to be a risk factor for falls.

Ramelteon, a melatonin receptor agonist, “takes advantage of the circadian system that secretes melatonin at night,” Dr. Buysse said. Ramelteon is short acting and has an active metabolite. Caution should be used with this drug when prescribed for patients also taking fluvoxamine, which inhibits some of the enzymes that degrade ramelteon.

Ramelteon has been shown to reduce sleep latency and increase total sleep time in younger and older adults. The drug appears to be less effective on wakefulness after sleep onset.

No evidence-based standards of practice or treatment algorithms exist for treating insomnia in older adults, “but I think that it makes sense to always use behavioral approaches before, or in combination with, medication,” Dr. Buysse said.

SAN JUAN, P.R. — Sleep disorders become more common with increasing age, but effective behavioral and pharmacologic therapies are available, sleep experts said at the annual meeting of the American Association for Geriatric Psychiatry.

“Most older adults are not being treated for their insomnia, and most older adults won't get a diagnosis of insomnia,” despite the high prevalence of the disorder among older individuals, said Dr. Phyllis C. Zee, medical director of the Sleep Disorders Center at Northwestern Memorial Hospital in Chicago.

There are several age-related changes in sleep architecture. The number of awakenings during sleep time increases, especially in early morning. The amount of light sleep is increased and the amount of deep sleep is decreased. There also is less REM sleep, said Dr. Zee, who also serves as a professor of neurology, neurobiology, and physiology at Northwestern University, Chicago.

Two major mechanisms regulate sleep in humans: the homeostatic drive and the circadian drive. Control of the circadian system resides in the suprachiasmatic nucleus, which provides timing information for physiologic, hormonal, and behavioral rhythms.

Several changes in circadian sleep rhythms come with age. The amplitude of circadian rhythms decreases, while the variability of circadian rhythms increases. “There's also a very noticeable advance in [the] phase of circadian rhythms,” Dr. Zee said. Severe disruptions of the sleep/wake cycle often occur among older adults with dementia and in those in nursing homes.

The homeostatic drive for sleep depends on accumulating enough hours of wakefulness to trigger sleep, and this drive is reset during sleep. It's thought that the homeostatic drive is regulated by the ventrolateral preoptic area of the hypothalamus.

It's important to understand these sleep mechanisms when treating sleep disorders. “There is not a thing you can do to make yourself go to sleep. … What you can do is arrange the circumstances and timing of your wakefulness in a way that makes the involuntary process of sleep more likely,” said Dr. Daniel J. Buysse, medical director of the sleep evaluation center at the Western Psychiatric Institute and Clinic of the University of Pittsburgh

To understand the patient's sleep habits, behavioral therapists start by asking about average time in bed, average rise time, total time in bed, time to fall asleep, amount of wakefulness during the night, and total wake time. Using this information, they calculate the amount of total sleep (total time in bed minus total wake time). For most individuals with insomnia, there is a discrepancy between the amount of sleep that they get and the amount of time they spend in bed, said Dr. Buysse, also a professor of psychiatry at the University of Pittsburgh.

Dr. Buysse and his colleagues have tested the effect of these changes in sleep behavior on sleep quality in a small study of 13 patients who made these changes, compared with 12 subjects who received basic sleep information.

Those in the active treatment group showed a significant improvement in sleep quality, while those in the control group showed no change.

In addition, those in the active treatment group showed improvement in sleep latency—how long it takes to fall asleep—and waking after sleep onset, while controls did not.

Pharmacologic management of acute and chronic insomnia includes benzodiazepine receptor agonists, melatonin, melatonin receptor agonists, and antidepressants.

In 2005, a National Institutes of Health state-of-the-science panel noted that hypnotics are efficacious in the short-term treatment of insomnia. However, with the exception of eszopiclone, the benefits have not been studied for long-term use.

Zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta)—benzodiazepine receptor agonists—are all indicated for the treatment of insomnia. “These drugs differ [from benzodiazepines] mainly in terms of their pharmacokinetics,” said Dr. Buysse. Otherwise, these drugs are quite similar to benzodiazepines. One note of caution, however: Benzodiazepines and related drugs have been shown to be a risk factor for falls.

Ramelteon, a melatonin receptor agonist, “takes advantage of the circadian system that secretes melatonin at night,” Dr. Buysse said. Ramelteon is short acting and has an active metabolite. Caution should be used with this drug when prescribed for patients also taking fluvoxamine, which inhibits some of the enzymes that degrade ramelteon.

Ramelteon has been shown to reduce sleep latency and increase total sleep time in younger and older adults. The drug appears to be less effective on wakefulness after sleep onset.

No evidence-based standards of practice or treatment algorithms exist for treating insomnia in older adults, “but I think that it makes sense to always use behavioral approaches before, or in combination with, medication,” Dr. Buysse said.

WASHINGTON — The number of methicillin-resistant Staphylococcus aureus infections has dramatically risen in recent years, and more and more cases are community acquired, at least in one emergency department, Dr. Mary-Claire Roghmann said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“We had more than a doubling [in new cases of methicillin-resistant S. aureus] from 2003 to 2004,” said Dr. Roghmann, the hospital epidemiologist for Veterans Affairs Maryland Health Care System. The ED at Baltimore VA Medical Center sees about 85 patients per day.

Tipped off by ED physicians that more MRSA cases seemed to be coming in, Dr. Roghmann and her colleagues identified patients with MRSA isolated for the first time for that patient from a culture taken in the ED. They discovered an increase in new cases of MRSA in the ED, starting with 0.2 new MRSA cases per 1,000 ED visits in 2001 and more than doubling from 1.1 to 2.6 new MRSA cases per 1,000 ED visits from 2003 to 2004.

To learn more about these cases, the researchers accessed data from the VA's patient records system. They excluded any patients with a history of MRSA prior to the ED visit. Specifically, they looked at type of infection, antibiotic susceptibility, and risk factors for hospital-acquired MRSA, said Dr. Roghmann, also of the University of Maryland in Baltimore.

They defined type of infection as a positive culture from the site and also signs and symptoms of infection at the site. Risk factors for hospital-acquired MRSA infection included history of hospitalization, surgery, dialysis, or residence in a long-term care facility in the last year. Patients were excluded if they had a percutaneous medical device or indwelling catheter at the time of the culture. Patients without any of these risk factors were determined to have community-acquired MRSA.

In 2004, there were 90 patients who met the criteria for newly acquired MRSA based on cultures from the ED. “Of these, 58% had community-acquired MRSA. The vast majority of patients had skin and soft tissue infections,” Dr. Roghmann said at the meeting, which was sponsored by the American Society for Microbiology.

In terms of antibiotic susceptibility, community-acquired MRSA cultures were more likely than were health care-acquired MRSA cultures to be susceptible to clindamycin and tetracycline.

The emergency physicians had also indicated that there seemed to be more skin and soft tissue infections. To determine whether there was also an increase in skin and soft tissue infections during the same time period, the researchers looked at visits to the ED with ICD-9 codes specific to those infections.

“There has been almost a doubling of the incidence rate of skin and soft tissue-related visits to our ED during this period,” said Dr. Roghmann. The number of these visits per 1,000 ED visits rose from 26 in 2001 to 54 in 2003.

WASHINGTON — The number of methicillin-resistant Staphylococcus aureus infections has dramatically risen in recent years, and more and more cases are community acquired, at least in one emergency department, Dr. Mary-Claire Roghmann said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“We had more than a doubling [in new cases of methicillin-resistant S. aureus] from 2003 to 2004,” said Dr. Roghmann, the hospital epidemiologist for Veterans Affairs Maryland Health Care System. The ED at Baltimore VA Medical Center sees about 85 patients per day.

Tipped off by ED physicians that more MRSA cases seemed to be coming in, Dr. Roghmann and her colleagues identified patients with MRSA isolated for the first time for that patient from a culture taken in the ED. They discovered an increase in new cases of MRSA in the ED, starting with 0.2 new MRSA cases per 1,000 ED visits in 2001 and more than doubling from 1.1 to 2.6 new MRSA cases per 1,000 ED visits from 2003 to 2004.

To learn more about these cases, the researchers accessed data from the VA's patient records system. They excluded any patients with a history of MRSA prior to the ED visit. Specifically, they looked at type of infection, antibiotic susceptibility, and risk factors for hospital-acquired MRSA, said Dr. Roghmann, also of the University of Maryland in Baltimore.

They defined type of infection as a positive culture from the site and also signs and symptoms of infection at the site. Risk factors for hospital-acquired MRSA infection included history of hospitalization, surgery, dialysis, or residence in a long-term care facility in the last year. Patients were excluded if they had a percutaneous medical device or indwelling catheter at the time of the culture. Patients without any of these risk factors were determined to have community-acquired MRSA.

In 2004, there were 90 patients who met the criteria for newly acquired MRSA based on cultures from the ED. “Of these, 58% had community-acquired MRSA. The vast majority of patients had skin and soft tissue infections,” Dr. Roghmann said at the meeting, which was sponsored by the American Society for Microbiology.

In terms of antibiotic susceptibility, community-acquired MRSA cultures were more likely than were health care-acquired MRSA cultures to be susceptible to clindamycin and tetracycline.

The emergency physicians had also indicated that there seemed to be more skin and soft tissue infections. To determine whether there was also an increase in skin and soft tissue infections during the same time period, the researchers looked at visits to the ED with ICD-9 codes specific to those infections.

“There has been almost a doubling of the incidence rate of skin and soft tissue-related visits to our ED during this period,” said Dr. Roghmann. The number of these visits per 1,000 ED visits rose from 26 in 2001 to 54 in 2003.

WASHINGTON — The number of methicillin-resistant Staphylococcus aureus infections has dramatically risen in recent years, and more and more cases are community acquired, at least in one emergency department, Dr. Mary-Claire Roghmann said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“We had more than a doubling [in new cases of methicillin-resistant S. aureus] from 2003 to 2004,” said Dr. Roghmann, the hospital epidemiologist for Veterans Affairs Maryland Health Care System. The ED at Baltimore VA Medical Center sees about 85 patients per day.

Tipped off by ED physicians that more MRSA cases seemed to be coming in, Dr. Roghmann and her colleagues identified patients with MRSA isolated for the first time for that patient from a culture taken in the ED. They discovered an increase in new cases of MRSA in the ED, starting with 0.2 new MRSA cases per 1,000 ED visits in 2001 and more than doubling from 1.1 to 2.6 new MRSA cases per 1,000 ED visits from 2003 to 2004.

To learn more about these cases, the researchers accessed data from the VA's patient records system. They excluded any patients with a history of MRSA prior to the ED visit. Specifically, they looked at type of infection, antibiotic susceptibility, and risk factors for hospital-acquired MRSA, said Dr. Roghmann, also of the University of Maryland in Baltimore.

They defined type of infection as a positive culture from the site and also signs and symptoms of infection at the site. Risk factors for hospital-acquired MRSA infection included history of hospitalization, surgery, dialysis, or residence in a long-term care facility in the last year. Patients were excluded if they had a percutaneous medical device or indwelling catheter at the time of the culture. Patients without any of these risk factors were determined to have community-acquired MRSA.

In 2004, there were 90 patients who met the criteria for newly acquired MRSA based on cultures from the ED. “Of these, 58% had community-acquired MRSA. The vast majority of patients had skin and soft tissue infections,” Dr. Roghmann said at the meeting, which was sponsored by the American Society for Microbiology.

In terms of antibiotic susceptibility, community-acquired MRSA cultures were more likely than were health care-acquired MRSA cultures to be susceptible to clindamycin and tetracycline.

The emergency physicians had also indicated that there seemed to be more skin and soft tissue infections. To determine whether there was also an increase in skin and soft tissue infections during the same time period, the researchers looked at visits to the ED with ICD-9 codes specific to those infections.

“There has been almost a doubling of the incidence rate of skin and soft tissue-related visits to our ED during this period,” said Dr. Roghmann. The number of these visits per 1,000 ED visits rose from 26 in 2001 to 54 in 2003.

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism; 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers. “So there seems to be, in this study, no effect of smoking on development of overt hypothyroidism,” he said.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients.

In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that the liver detoxifies the cyanide in smoke to give thiocyanate, which reduces iodide transport into the cell in a manner similar to decreasing iodine intake. The thyroid cells compensate by trying to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smokers also might be protected against autoimmunity, as they have lower levels of thyroid autoantibodies than nonsmokers, said Dr. Laurberg.

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism; 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers. “So there seems to be, in this study, no effect of smoking on development of overt hypothyroidism,” he said.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients.

In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that the liver detoxifies the cyanide in smoke to give thiocyanate, which reduces iodide transport into the cell in a manner similar to decreasing iodine intake. The thyroid cells compensate by trying to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smokers also might be protected against autoimmunity, as they have lower levels of thyroid autoantibodies than nonsmokers, said Dr. Laurberg.

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism; 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers. “So there seems to be, in this study, no effect of smoking on development of overt hypothyroidism,” he said.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients.

In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that the liver detoxifies the cyanide in smoke to give thiocyanate, which reduces iodide transport into the cell in a manner similar to decreasing iodine intake. The thyroid cells compensate by trying to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smokers also might be protected against autoimmunity, as they have lower levels of thyroid autoantibodies than nonsmokers, said Dr. Laurberg.

Two additional deaths after medical abortion with mifepristone (Mifeprex) have prompted the Food and Drug Administration to issue a public health advisory alerting health care providers and advising review of prescribing information.

The drug's manufacturer, Danco Laboratories, notified the agency of the deaths, which took place in the United States.

One of the deaths has since been determined to not be related to either an abortion or to the use of mifepristone and misoprostol. The FDA is investigating the other death, which involved symptoms of infection.

The agency advises physicians to discuss with their patients the risk of sepsis as well as early signs and symptoms that may warrant immediate medical evaluation. In addition, the FDA advises physicians and emergency department personnel to investigate the possibility of sepsis in patients who are undergoing medical abortion and present with all of the following:

▸ Nausea, vomiting, or diarrhea.

▸ Weakness with or without abdominal pain.

▸ No fever or other signs of infection more than 24 hours after taking misoprostol.

Strong consideration should be given to obtaining a complete blood count to identify those patients with hidden infection.

The FDA recommends that if physicians suspect infection in patients with this presentation, they should consider immediately initiating treatment with antibiotics that include coverage of anaerobic bacteria, such as Clostridium sordellii. However, the agency does not recommend the use of prophylactic antibiotics at this time.

Four previous deaths from sepsis have been confirmed in U.S. women following medical abortion with mifepristone and misoprostol from September 2003 to June 2005. All four cases of fatal infection tested positive for C. sordellii.

For more information, go to: www.fda.gov/cder/drug/infopage/mifepristone

Two additional deaths after medical abortion with mifepristone (Mifeprex) have prompted the Food and Drug Administration to issue a public health advisory alerting health care providers and advising review of prescribing information.

The drug's manufacturer, Danco Laboratories, notified the agency of the deaths, which took place in the United States.

One of the deaths has since been determined to not be related to either an abortion or to the use of mifepristone and misoprostol. The FDA is investigating the other death, which involved symptoms of infection.

The agency advises physicians to discuss with their patients the risk of sepsis as well as early signs and symptoms that may warrant immediate medical evaluation. In addition, the FDA advises physicians and emergency department personnel to investigate the possibility of sepsis in patients who are undergoing medical abortion and present with all of the following:

▸ Nausea, vomiting, or diarrhea.

▸ Weakness with or without abdominal pain.

▸ No fever or other signs of infection more than 24 hours after taking misoprostol.

Strong consideration should be given to obtaining a complete blood count to identify those patients with hidden infection.

The FDA recommends that if physicians suspect infection in patients with this presentation, they should consider immediately initiating treatment with antibiotics that include coverage of anaerobic bacteria, such as Clostridium sordellii. However, the agency does not recommend the use of prophylactic antibiotics at this time.

Four previous deaths from sepsis have been confirmed in U.S. women following medical abortion with mifepristone and misoprostol from September 2003 to June 2005. All four cases of fatal infection tested positive for C. sordellii.

For more information, go to: www.fda.gov/cder/drug/infopage/mifepristone

Two additional deaths after medical abortion with mifepristone (Mifeprex) have prompted the Food and Drug Administration to issue a public health advisory alerting health care providers and advising review of prescribing information.

The drug's manufacturer, Danco Laboratories, notified the agency of the deaths, which took place in the United States.

One of the deaths has since been determined to not be related to either an abortion or to the use of mifepristone and misoprostol. The FDA is investigating the other death, which involved symptoms of infection.

The agency advises physicians to discuss with their patients the risk of sepsis as well as early signs and symptoms that may warrant immediate medical evaluation. In addition, the FDA advises physicians and emergency department personnel to investigate the possibility of sepsis in patients who are undergoing medical abortion and present with all of the following:

▸ Nausea, vomiting, or diarrhea.

▸ Weakness with or without abdominal pain.

▸ No fever or other signs of infection more than 24 hours after taking misoprostol.

Strong consideration should be given to obtaining a complete blood count to identify those patients with hidden infection.

The FDA recommends that if physicians suspect infection in patients with this presentation, they should consider immediately initiating treatment with antibiotics that include coverage of anaerobic bacteria, such as Clostridium sordellii. However, the agency does not recommend the use of prophylactic antibiotics at this time.

Four previous deaths from sepsis have been confirmed in U.S. women following medical abortion with mifepristone and misoprostol from September 2003 to June 2005. All four cases of fatal infection tested positive for C. sordellii.

For more information, go to: www.fda.gov/cder/drug/infopage/mifepristone

WASHINGTON — Any decision to choose between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been discussed, concluded an independent panel of experts on cesarean section.

“Her decision should be honored,” Dr. Mary E. D'Alton, panel chairperson, said at a conference on cesarean delivery sponsored by the National Institutes of Health.

The panel, convened to assess the science regarding cesarean delivery on maternal request, concluded that available information on the risks and benefits of C-section on maternal request versus planned vaginal birth does not provide the basis for a recommendation in either direction.

The panel defined C-section on maternal request as a mother's request for a cesarean delivery for a singleton pregnancy when she has no established medical indication for the procedure. This is distinct from emergency C-section or C-section performed after attempted vaginal delivery.

“We don't believe [C-section on maternal request] should be discouraged or encouraged. We believe there should be a full discussion of the risks and benefits as we know them right now,” said Dr. D'Alton, chair of obstetrics and gynecology at Columbia University in New York.

Many believe that the rate of cesarean delivery by maternal request is increasing, with domestic and international estimates ranging from 4% to 18% of all cesarean deliveries. In 2004, almost one-third (29%) of all U.S. live births were by C-section, the highest rate ever reported.

Cesarean delivery on maternal request “may be a reasonable alternative” to planned vaginal delivery, after thorough discussion with the patient, the panel of 18 experts said in a draft state-of-the-science report. “When a provider cannot support this request, it is appropriate to refer the woman to another provider.”

The panel advised against C-section for women desiring to have several children, but did not specify a number to use as a cutoff. Evidence seems to indicate that the risks of placenta previa and accreta rise with each C-section. Planned vaginal delivery “provides an improved benefit/risk ratio for women who desire several children,” the panel concluded.

The panel also recommended that C-section on maternal request should not be performed prior to 39 weeks or without verification of lung maturity. Evidence suggests an increased risk of neonate respiratory morbidity with C-section, compared with vaginal delivery.

The panel encouraged physicians to discuss with a woman her reasons for requesting a C-section, and to discuss pain management options if she is motivated by a fear of pain. “Efforts must be made to assure availability of pain management services for all women,” the panel said.

Good quality data on the benefits and risks of C-section on maternal request are limited. It is often difficult to retrospectively assess whether a C-section was genuinely requested by the mother. Frequently, emergency C-sections and/or C-sections following a trial of labor are lumped in with the ones by maternal request.

The interpretation of many outcome variables was confounded by a lack of appropriate comparison groups, inconsistency in outcome definitions, and the frequent use of composite outcomes. The panel identified two maternal outcome variables—both short term—with moderate-quality evidence.

One suggests a lower risk of blood loss associated with planned C-section than with the combination of planned vaginal delivery and unplanned C-section. The second indicates that C-section was associated with longer hospital stays than was vaginal delivery. The panel also identified one neonatal outcome with moderate-quality evidence—increased respiratory morbidity associated with planned C-section.

The final statement is available at http://consensus.nih.gov

WASHINGTON — Any decision to choose between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been discussed, concluded an independent panel of experts on cesarean section.

“Her decision should be honored,” Dr. Mary E. D'Alton, panel chairperson, said at a conference on cesarean delivery sponsored by the National Institutes of Health.

The panel, convened to assess the science regarding cesarean delivery on maternal request, concluded that available information on the risks and benefits of C-section on maternal request versus planned vaginal birth does not provide the basis for a recommendation in either direction.

The panel defined C-section on maternal request as a mother's request for a cesarean delivery for a singleton pregnancy when she has no established medical indication for the procedure. This is distinct from emergency C-section or C-section performed after attempted vaginal delivery.

“We don't believe [C-section on maternal request] should be discouraged or encouraged. We believe there should be a full discussion of the risks and benefits as we know them right now,” said Dr. D'Alton, chair of obstetrics and gynecology at Columbia University in New York.

Many believe that the rate of cesarean delivery by maternal request is increasing, with domestic and international estimates ranging from 4% to 18% of all cesarean deliveries. In 2004, almost one-third (29%) of all U.S. live births were by C-section, the highest rate ever reported.

Cesarean delivery on maternal request “may be a reasonable alternative” to planned vaginal delivery, after thorough discussion with the patient, the panel of 18 experts said in a draft state-of-the-science report. “When a provider cannot support this request, it is appropriate to refer the woman to another provider.”

The panel advised against C-section for women desiring to have several children, but did not specify a number to use as a cutoff. Evidence seems to indicate that the risks of placenta previa and accreta rise with each C-section. Planned vaginal delivery “provides an improved benefit/risk ratio for women who desire several children,” the panel concluded.

The panel also recommended that C-section on maternal request should not be performed prior to 39 weeks or without verification of lung maturity. Evidence suggests an increased risk of neonate respiratory morbidity with C-section, compared with vaginal delivery.

The panel encouraged physicians to discuss with a woman her reasons for requesting a C-section, and to discuss pain management options if she is motivated by a fear of pain. “Efforts must be made to assure availability of pain management services for all women,” the panel said.

Good quality data on the benefits and risks of C-section on maternal request are limited. It is often difficult to retrospectively assess whether a C-section was genuinely requested by the mother. Frequently, emergency C-sections and/or C-sections following a trial of labor are lumped in with the ones by maternal request.

The interpretation of many outcome variables was confounded by a lack of appropriate comparison groups, inconsistency in outcome definitions, and the frequent use of composite outcomes. The panel identified two maternal outcome variables—both short term—with moderate-quality evidence.

One suggests a lower risk of blood loss associated with planned C-section than with the combination of planned vaginal delivery and unplanned C-section. The second indicates that C-section was associated with longer hospital stays than was vaginal delivery. The panel also identified one neonatal outcome with moderate-quality evidence—increased respiratory morbidity associated with planned C-section.

The final statement is available at http://consensus.nih.gov

WASHINGTON — Any decision to choose between cesarean delivery by maternal request or trial of labor ultimately lies with the woman, once the potential risks and benefits associated with C-section have been discussed, concluded an independent panel of experts on cesarean section.

“Her decision should be honored,” Dr. Mary E. D'Alton, panel chairperson, said at a conference on cesarean delivery sponsored by the National Institutes of Health.

The panel, convened to assess the science regarding cesarean delivery on maternal request, concluded that available information on the risks and benefits of C-section on maternal request versus planned vaginal birth does not provide the basis for a recommendation in either direction.

The panel defined C-section on maternal request as a mother's request for a cesarean delivery for a singleton pregnancy when she has no established medical indication for the procedure. This is distinct from emergency C-section or C-section performed after attempted vaginal delivery.

“We don't believe [C-section on maternal request] should be discouraged or encouraged. We believe there should be a full discussion of the risks and benefits as we know them right now,” said Dr. D'Alton, chair of obstetrics and gynecology at Columbia University in New York.

Many believe that the rate of cesarean delivery by maternal request is increasing, with domestic and international estimates ranging from 4% to 18% of all cesarean deliveries. In 2004, almost one-third (29%) of all U.S. live births were by C-section, the highest rate ever reported.

Cesarean delivery on maternal request “may be a reasonable alternative” to planned vaginal delivery, after thorough discussion with the patient, the panel of 18 experts said in a draft state-of-the-science report. “When a provider cannot support this request, it is appropriate to refer the woman to another provider.”

The panel advised against C-section for women desiring to have several children, but did not specify a number to use as a cutoff. Evidence seems to indicate that the risks of placenta previa and accreta rise with each C-section. Planned vaginal delivery “provides an improved benefit/risk ratio for women who desire several children,” the panel concluded.

The panel also recommended that C-section on maternal request should not be performed prior to 39 weeks or without verification of lung maturity. Evidence suggests an increased risk of neonate respiratory morbidity with C-section, compared with vaginal delivery.

The panel encouraged physicians to discuss with a woman her reasons for requesting a C-section, and to discuss pain management options if she is motivated by a fear of pain. “Efforts must be made to assure availability of pain management services for all women,” the panel said.

Good quality data on the benefits and risks of C-section on maternal request are limited. It is often difficult to retrospectively assess whether a C-section was genuinely requested by the mother. Frequently, emergency C-sections and/or C-sections following a trial of labor are lumped in with the ones by maternal request.

The interpretation of many outcome variables was confounded by a lack of appropriate comparison groups, inconsistency in outcome definitions, and the frequent use of composite outcomes. The panel identified two maternal outcome variables—both short term—with moderate-quality evidence.

One suggests a lower risk of blood loss associated with planned C-section than with the combination of planned vaginal delivery and unplanned C-section. The second indicates that C-section was associated with longer hospital stays than was vaginal delivery. The panel also identified one neonatal outcome with moderate-quality evidence—increased respiratory morbidity associated with planned C-section.

The final statement is available at http://consensus.nih.gov

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

It's no surprise that increasing dementia severity is a risk factor for unsafe driving. About 30% of demented people continue to drive. “We know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Despite the potential danger, few older adults with dementia want to stop driving. “It's no surprise that older adults do not want to relinquish driving,” he said. Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. Without the ability to drive, older adults are at greater risk for social isolation and depression.

For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up driving when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents, even “fender benders.”

▸ Receiving citations.

Driving simulators provide a safe testing environment and can help determine whether a person with dementia is safe on the roads.

Road tests, however, may be the standard by which other evaluation methods are measured, Dr. Morris said. These tests provide a reliable, direct measure of a person's driving ability but require special equipment and can be costly.

Finally, there is physician judgment based on information from the patient and family, cognitive measures, and physical examinations. Physicians actually do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family members if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is done in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“The most difficult part is, how do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

The family has to be involved in enforcing the decision. It's also important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

Dr. Morris recommended these Web sites for more information about older drivers or drivers with dementia:

▸ www.ama-assn.org/go/olderdrivers

▸ www.alz.org

▸ www.nhtsa.dot.gov

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

It's no surprise that increasing dementia severity is a risk factor for unsafe driving. About 30% of demented people continue to drive. “We know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Despite the potential danger, few older adults with dementia want to stop driving. “It's no surprise that older adults do not want to relinquish driving,” he said. Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. Without the ability to drive, older adults are at greater risk for social isolation and depression.

For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up driving when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents, even “fender benders.”

▸ Receiving citations.

Driving simulators provide a safe testing environment and can help determine whether a person with dementia is safe on the roads.

Road tests, however, may be the standard by which other evaluation methods are measured, Dr. Morris said. These tests provide a reliable, direct measure of a person's driving ability but require special equipment and can be costly.

Finally, there is physician judgment based on information from the patient and family, cognitive measures, and physical examinations. Physicians actually do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family members if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is done in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“The most difficult part is, how do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

The family has to be involved in enforcing the decision. It's also important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

Dr. Morris recommended these Web sites for more information about older drivers or drivers with dementia:

▸ www.ama-assn.org/go/olderdrivers

▸ www.alz.org

▸ www.nhtsa.dot.gov

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

It's no surprise that increasing dementia severity is a risk factor for unsafe driving. About 30% of demented people continue to drive. “We know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Despite the potential danger, few older adults with dementia want to stop driving. “It's no surprise that older adults do not want to relinquish driving,” he said. Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. Without the ability to drive, older adults are at greater risk for social isolation and depression.

For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up driving when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents, even “fender benders.”

▸ Receiving citations.

Driving simulators provide a safe testing environment and can help determine whether a person with dementia is safe on the roads.

Road tests, however, may be the standard by which other evaluation methods are measured, Dr. Morris said. These tests provide a reliable, direct measure of a person's driving ability but require special equipment and can be costly.

Finally, there is physician judgment based on information from the patient and family, cognitive measures, and physical examinations. Physicians actually do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family members if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is done in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“The most difficult part is, how do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

The family has to be involved in enforcing the decision. It's also important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

Dr. Morris recommended these Web sites for more information about older drivers or drivers with dementia:

▸ www.ama-assn.org/go/olderdrivers

▸ www.alz.org

▸ www.nhtsa.dot.gov

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism, 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients. In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that smoking produces cyanide, which is detoxified in the liver and results in thiocyanate. A competitive inhibitor like thiocyanate reduces iodide transport into the cell in a manner similar to decreasing iodine intake.

Due to autoregulation, the thyroid cells compensate by attempting to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smoking also might protect against autoimmunity, he said. Smokers have been found to have lower levels of thyroid autoantibodies than nonsmokers.

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism, 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients. In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that smoking produces cyanide, which is detoxified in the liver and results in thiocyanate. A competitive inhibitor like thiocyanate reduces iodide transport into the cell in a manner similar to decreasing iodine intake.

Due to autoregulation, the thyroid cells compensate by attempting to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smoking also might protect against autoimmunity, he said. Smokers have been found to have lower levels of thyroid autoantibodies than nonsmokers.

WASHINGTON — Smoking was associated with an increased risk of subclinical hypothyroidism but no increase in clinical disease in unpublished data from the Danish Investigation of Iodine Intake and Thyroid Disease.

Dr. Peter Laurberg, a professor of endocrinology at Aarhus University Hospital in Denmark, reported on 140 subjects with spontaneous hypothyroidism, 42 were current smokers, 47 were previous smokers, and 51 were nonsmokers. Of 559 healthy control subjects, 193 were current smokers, 147 were previous smokers, and 219 were nonsmokers.

The study followed a cohort of individuals prior to mandatory iodine supplementation in Denmark in 2000 and involves a prospective registry of hyper- and hypothyroid patients. In an examination of smoking and subclinical disease, 1,619 smokers had a nonsignificant odds ratio of 1.15 for having subclinical hyperthyroidism compared with 2,800 nonsmokers. Alternatively, smokers had an odds ratio of 0.47 for subclinical hypothyroidism.

One proposed mechanism for this observation is that smoking produces cyanide, which is detoxified in the liver and results in thiocyanate. A competitive inhibitor like thiocyanate reduces iodide transport into the cell in a manner similar to decreasing iodine intake.

Due to autoregulation, the thyroid cells compensate by attempting to pump more iodide into the cell. However, the upregulation of these processes produces peroxide. “So if you are deficient over a long period without being severely deficient … you get a thyroid with irregular growth and function and necrosis,” said Dr. Laurberg.

Smoking also might protect against autoimmunity, he said. Smokers have been found to have lower levels of thyroid autoantibodies than nonsmokers.

Power injection of contrast through an intravenous line during MRI is frequently used to assess cerebral perfusion in adults, but use of this technique in neonates is problematic for a number of reasons, according to Dr. Ellen Grant, director of pediatric radiology at Massachusetts General Hospital in Boston.

Many contrast agents used for MRI are not specifically indicated for very young children. The IV line also may be placed in an awkward or precarious position and may not be suitable for bolus injection.

“The other problem with these bolus injections of contrast for perfusion used on adults is that they emphasize all of the [cerebral] vessels. Neonates have relatively large veins on the cortical surface so that's all you see—cortical veins. I don't get much information about [deeper] cortical perfusion,” said Dr. Grant.

Arterial spin labeling MRI (ASL-MRI) eliminates the need for the injection of a contrast bolus by magnetically labeling blood that flows from the heart past an external radiofrequency pulse sequencer placed at the infant's neck. The magnetically labeled blood perfuses into the brain tissue, altering the tissue's magnetization. By making assumptions about a few parameters, such as the distance between the point of blood magnetization at the neck and any given point in the brain, the technique can be used to produce quantitative maps of cerebral blood flow, such as the image seen at right.

“I think the most important thing is that it gives you more reproducible data than the bolus perfusion method. It's easier to compare subject to subject or one subject over several time points,” said Dr. Grant.

Another advantage of this method over a contrast bolus is that the blood is tagged right as it goes into the brain, instead of having to go through the heart and lungs, which spreads out the bolus.

ASL-MRI is “kind of like a poor man's look into brain function because it's blood flow, which is linked to metabolism,” said Dr. Grant.

The technique reveals injury in areas that looked normal on diffusion-weighted imaging,” said Dr. Grant. “We want to know not only what's happening to the area that shows up as necrotic on a diffusion scan, we want to know what's happening to the rest of the brain.”

This information may be particularly important in the neonatal brain because animal models of neonatal brain injury indicate that apoptotic cell death is often the predominant form of cell death. “We know that diffusion-weighted imaging picks up necrotic cell death but we're probably not picking up that other possibly dominant proportion that is apoptotic,” said Dr. Grant.

Dr. Grant uses a 1.5-T scanner to image infants, who have been fed and swaddled tightly so that they fall asleep. “Having 3 tesla does give you increased signal to noise but with the ASL sequence we have from Dr. David Alsop [of Harvard University in Boston], we get good signal at 1.5 T,” said Dr. Grant. One advantage in imaging babies is that blood flow is much faster than in adults. “Even in a newborn I'm getting decent images that I can start to see different patterns of blood flow with different types of injuries,” she said. The sequence, written by Dr. Alsop, is fast-spin echo-based, and it provides whole-brain coverage rather than a few slices. The process takes 5–6 minutes.

ASL-MRI will help researchers better understand the health of neurons not identified as injured using conventional scanning techniques. Dr. Grant and her colleagues are starting to couple blood-flow imaging with quantitative optical imaging to come up with estimates of the cerebral metabolic rate of oxygen, which can reveal the functional status of brain tissue.

The technique may prove to be useful in the early stratification of neonates and infants with developmental delays without exposing them to radiation, said Dr. Grant.

Power injection of contrast through an intravenous line during MRI is frequently used to assess cerebral perfusion in adults, but use of this technique in neonates is problematic for a number of reasons, according to Dr. Ellen Grant, director of pediatric radiology at Massachusetts General Hospital in Boston.

Many contrast agents used for MRI are not specifically indicated for very young children. The IV line also may be placed in an awkward or precarious position and may not be suitable for bolus injection.

“The other problem with these bolus injections of contrast for perfusion used on adults is that they emphasize all of the [cerebral] vessels. Neonates have relatively large veins on the cortical surface so that's all you see—cortical veins. I don't get much information about [deeper] cortical perfusion,” said Dr. Grant.

Arterial spin labeling MRI (ASL-MRI) eliminates the need for the injection of a contrast bolus by magnetically labeling blood that flows from the heart past an external radiofrequency pulse sequencer placed at the infant's neck. The magnetically labeled blood perfuses into the brain tissue, altering the tissue's magnetization. By making assumptions about a few parameters, such as the distance between the point of blood magnetization at the neck and any given point in the brain, the technique can be used to produce quantitative maps of cerebral blood flow, such as the image seen at right.

“I think the most important thing is that it gives you more reproducible data than the bolus perfusion method. It's easier to compare subject to subject or one subject over several time points,” said Dr. Grant.

Another advantage of this method over a contrast bolus is that the blood is tagged right as it goes into the brain, instead of having to go through the heart and lungs, which spreads out the bolus.

ASL-MRI is “kind of like a poor man's look into brain function because it's blood flow, which is linked to metabolism,” said Dr. Grant.

The technique reveals injury in areas that looked normal on diffusion-weighted imaging,” said Dr. Grant. “We want to know not only what's happening to the area that shows up as necrotic on a diffusion scan, we want to know what's happening to the rest of the brain.”

This information may be particularly important in the neonatal brain because animal models of neonatal brain injury indicate that apoptotic cell death is often the predominant form of cell death. “We know that diffusion-weighted imaging picks up necrotic cell death but we're probably not picking up that other possibly dominant proportion that is apoptotic,” said Dr. Grant.

Dr. Grant uses a 1.5-T scanner to image infants, who have been fed and swaddled tightly so that they fall asleep. “Having 3 tesla does give you increased signal to noise but with the ASL sequence we have from Dr. David Alsop [of Harvard University in Boston], we get good signal at 1.5 T,” said Dr. Grant. One advantage in imaging babies is that blood flow is much faster than in adults. “Even in a newborn I'm getting decent images that I can start to see different patterns of blood flow with different types of injuries,” she said. The sequence, written by Dr. Alsop, is fast-spin echo-based, and it provides whole-brain coverage rather than a few slices. The process takes 5–6 minutes.

ASL-MRI will help researchers better understand the health of neurons not identified as injured using conventional scanning techniques. Dr. Grant and her colleagues are starting to couple blood-flow imaging with quantitative optical imaging to come up with estimates of the cerebral metabolic rate of oxygen, which can reveal the functional status of brain tissue.

The technique may prove to be useful in the early stratification of neonates and infants with developmental delays without exposing them to radiation, said Dr. Grant.

Power injection of contrast through an intravenous line during MRI is frequently used to assess cerebral perfusion in adults, but use of this technique in neonates is problematic for a number of reasons, according to Dr. Ellen Grant, director of pediatric radiology at Massachusetts General Hospital in Boston.

Many contrast agents used for MRI are not specifically indicated for very young children. The IV line also may be placed in an awkward or precarious position and may not be suitable for bolus injection.

“The other problem with these bolus injections of contrast for perfusion used on adults is that they emphasize all of the [cerebral] vessels. Neonates have relatively large veins on the cortical surface so that's all you see—cortical veins. I don't get much information about [deeper] cortical perfusion,” said Dr. Grant.

Arterial spin labeling MRI (ASL-MRI) eliminates the need for the injection of a contrast bolus by magnetically labeling blood that flows from the heart past an external radiofrequency pulse sequencer placed at the infant's neck. The magnetically labeled blood perfuses into the brain tissue, altering the tissue's magnetization. By making assumptions about a few parameters, such as the distance between the point of blood magnetization at the neck and any given point in the brain, the technique can be used to produce quantitative maps of cerebral blood flow, such as the image seen at right.

“I think the most important thing is that it gives you more reproducible data than the bolus perfusion method. It's easier to compare subject to subject or one subject over several time points,” said Dr. Grant.

Another advantage of this method over a contrast bolus is that the blood is tagged right as it goes into the brain, instead of having to go through the heart and lungs, which spreads out the bolus.

ASL-MRI is “kind of like a poor man's look into brain function because it's blood flow, which is linked to metabolism,” said Dr. Grant.

The technique reveals injury in areas that looked normal on diffusion-weighted imaging,” said Dr. Grant. “We want to know not only what's happening to the area that shows up as necrotic on a diffusion scan, we want to know what's happening to the rest of the brain.”

This information may be particularly important in the neonatal brain because animal models of neonatal brain injury indicate that apoptotic cell death is often the predominant form of cell death. “We know that diffusion-weighted imaging picks up necrotic cell death but we're probably not picking up that other possibly dominant proportion that is apoptotic,” said Dr. Grant.

Dr. Grant uses a 1.5-T scanner to image infants, who have been fed and swaddled tightly so that they fall asleep. “Having 3 tesla does give you increased signal to noise but with the ASL sequence we have from Dr. David Alsop [of Harvard University in Boston], we get good signal at 1.5 T,” said Dr. Grant. One advantage in imaging babies is that blood flow is much faster than in adults. “Even in a newborn I'm getting decent images that I can start to see different patterns of blood flow with different types of injuries,” she said. The sequence, written by Dr. Alsop, is fast-spin echo-based, and it provides whole-brain coverage rather than a few slices. The process takes 5–6 minutes.

ASL-MRI will help researchers better understand the health of neurons not identified as injured using conventional scanning techniques. Dr. Grant and her colleagues are starting to couple blood-flow imaging with quantitative optical imaging to come up with estimates of the cerebral metabolic rate of oxygen, which can reveal the functional status of brain tissue.

The technique may prove to be useful in the early stratification of neonates and infants with developmental delays without exposing them to radiation, said Dr. Grant.

WASHINGTON — Cognitive changes in Parkinson's disease can be seen on positron emission tomography imaging and correlate well with psychological tests, according to data reported in a poster at the World Parkinson Congress.

Dr. David Eidelberg, director of the Center for Neurosciences, and his colleagues at The Feinstein Institute for Medical Research at the North Shore-Long Island Jewish Health System in Manhasset, New York, studied 47 Parkinson's disease (PD) patients (31 men and 16 women) using 18fluorodeoxyglucose PET imaging to identify metabolic patterns associated with cognitive function in PD. In addition to affect, four domains—memory/verbal learning, attention/executive function, visuospatial function, and general cognitive function—were assessed with neuropsychological testing. “We looked for patterns in the brain that correlated with their psychologic performance,” Dr. Eidelberg said.

The patients were an average age of 58 years and had PD for an average of 12 years. General cognitive function was assessed using the Mini-Mental State Examination. PET scans were analyzed using network analysis that isolates different aspects of neural circuits that correlate with a person's cognitive function. Analysis revealed a significant pattern of covarying metabolic reductions in the parietal cortex, anterior cingulate area, and medial frontal lobe (see illustration in which the left and right panels represent the right and left hemispheres, respectively). This pattern correlated negatively with performance on the California Verbal Learning test, Stroop test, digit symbol test, and Hooper Visual Organization test, and positively with the Trail Making test, but not with affect. The researchers also validated this PD cognitive-related pattern (PDCP) in 21 patients with PD, who were scanned twice over a 2-month period. Comparison of the test-retest results showed that PDCP was highly reliable as a predictor of psychological performance. “What makes this appealing is that there is a way to measure cognitive function indirectly,” Dr. Eidelberg said.

The researchers also investigated two clinical applications for the technique. First, they computed the PD-related pattern (motor function) and PDCP in 15 early-stage patients, who were scanned at baseline and at 2 and 4 years. PDCP expression was significantly elevated at the third time point with respect to both baseline and the second time point. “The motor pattern is higher typically and progresses like a straight line. The PDCP starts slower and may not be a straight line in terms of its evolution,” he said.

In PD the motor and cognitive changes have different time courses. Cognitive changes have a later evolution in the course of the disease. “Treating the motor component of Parkinson's disease, which is what we all do, does not appear to really do much for cognition and at times makes it worse,” Dr. Eidelberg said.

The researchers also prospectively computed PDCP expression for PD patients on and off treatment during consecutive days. “While the levodopa and deep brain stimulation were very helpful in the elevated PD-related pattern network, the same interventions in the same people had no real effect on PDCP,” he said. This finding implies that new therapies are needed to treat cognitive changes.

The data validate PDCP as a stable and reproducible imaging marker of cognitive function in PD. Unlike the PD motor-related pattern, the nonmotor pattern evolves slowly over time and its expression is not altered by therapeutic interventions targeting the motor manifestation of PD.

Metabolic decreases in the prefrontal/frontal cortex (in green; Brodmann areas 9, 46) and parietal cortex (Brodmann 7, 39, 40) typify PDCP for mild/moderate cognitive impairment. Courtesy Dr. David Eidelberg

WASHINGTON — Cognitive changes in Parkinson's disease can be seen on positron emission tomography imaging and correlate well with psychological tests, according to data reported in a poster at the World Parkinson Congress.

Dr. David Eidelberg, director of the Center for Neurosciences, and his colleagues at The Feinstein Institute for Medical Research at the North Shore-Long Island Jewish Health System in Manhasset, New York, studied 47 Parkinson's disease (PD) patients (31 men and 16 women) using 18fluorodeoxyglucose PET imaging to identify metabolic patterns associated with cognitive function in PD. In addition to affect, four domains—memory/verbal learning, attention/executive function, visuospatial function, and general cognitive function—were assessed with neuropsychological testing. “We looked for patterns in the brain that correlated with their psychologic performance,” Dr. Eidelberg said.

The patients were an average age of 58 years and had PD for an average of 12 years. General cognitive function was assessed using the Mini-Mental State Examination. PET scans were analyzed using network analysis that isolates different aspects of neural circuits that correlate with a person's cognitive function. Analysis revealed a significant pattern of covarying metabolic reductions in the parietal cortex, anterior cingulate area, and medial frontal lobe (see illustration in which the left and right panels represent the right and left hemispheres, respectively). This pattern correlated negatively with performance on the California Verbal Learning test, Stroop test, digit symbol test, and Hooper Visual Organization test, and positively with the Trail Making test, but not with affect. The researchers also validated this PD cognitive-related pattern (PDCP) in 21 patients with PD, who were scanned twice over a 2-month period. Comparison of the test-retest results showed that PDCP was highly reliable as a predictor of psychological performance. “What makes this appealing is that there is a way to measure cognitive function indirectly,” Dr. Eidelberg said.

The researchers also investigated two clinical applications for the technique. First, they computed the PD-related pattern (motor function) and PDCP in 15 early-stage patients, who were scanned at baseline and at 2 and 4 years. PDCP expression was significantly elevated at the third time point with respect to both baseline and the second time point. “The motor pattern is higher typically and progresses like a straight line. The PDCP starts slower and may not be a straight line in terms of its evolution,” he said.

In PD the motor and cognitive changes have different time courses. Cognitive changes have a later evolution in the course of the disease. “Treating the motor component of Parkinson's disease, which is what we all do, does not appear to really do much for cognition and at times makes it worse,” Dr. Eidelberg said.

The researchers also prospectively computed PDCP expression for PD patients on and off treatment during consecutive days. “While the levodopa and deep brain stimulation were very helpful in the elevated PD-related pattern network, the same interventions in the same people had no real effect on PDCP,” he said. This finding implies that new therapies are needed to treat cognitive changes.

The data validate PDCP as a stable and reproducible imaging marker of cognitive function in PD. Unlike the PD motor-related pattern, the nonmotor pattern evolves slowly over time and its expression is not altered by therapeutic interventions targeting the motor manifestation of PD.

Metabolic decreases in the prefrontal/frontal cortex (in green; Brodmann areas 9, 46) and parietal cortex (Brodmann 7, 39, 40) typify PDCP for mild/moderate cognitive impairment. Courtesy Dr. David Eidelberg

WASHINGTON — Cognitive changes in Parkinson's disease can be seen on positron emission tomography imaging and correlate well with psychological tests, according to data reported in a poster at the World Parkinson Congress.

Dr. David Eidelberg, director of the Center for Neurosciences, and his colleagues at The Feinstein Institute for Medical Research at the North Shore-Long Island Jewish Health System in Manhasset, New York, studied 47 Parkinson's disease (PD) patients (31 men and 16 women) using 18fluorodeoxyglucose PET imaging to identify metabolic patterns associated with cognitive function in PD. In addition to affect, four domains—memory/verbal learning, attention/executive function, visuospatial function, and general cognitive function—were assessed with neuropsychological testing. “We looked for patterns in the brain that correlated with their psychologic performance,” Dr. Eidelberg said.

The patients were an average age of 58 years and had PD for an average of 12 years. General cognitive function was assessed using the Mini-Mental State Examination. PET scans were analyzed using network analysis that isolates different aspects of neural circuits that correlate with a person's cognitive function. Analysis revealed a significant pattern of covarying metabolic reductions in the parietal cortex, anterior cingulate area, and medial frontal lobe (see illustration in which the left and right panels represent the right and left hemispheres, respectively). This pattern correlated negatively with performance on the California Verbal Learning test, Stroop test, digit symbol test, and Hooper Visual Organization test, and positively with the Trail Making test, but not with affect. The researchers also validated this PD cognitive-related pattern (PDCP) in 21 patients with PD, who were scanned twice over a 2-month period. Comparison of the test-retest results showed that PDCP was highly reliable as a predictor of psychological performance. “What makes this appealing is that there is a way to measure cognitive function indirectly,” Dr. Eidelberg said.

The researchers also investigated two clinical applications for the technique. First, they computed the PD-related pattern (motor function) and PDCP in 15 early-stage patients, who were scanned at baseline and at 2 and 4 years. PDCP expression was significantly elevated at the third time point with respect to both baseline and the second time point. “The motor pattern is higher typically and progresses like a straight line. The PDCP starts slower and may not be a straight line in terms of its evolution,” he said.

In PD the motor and cognitive changes have different time courses. Cognitive changes have a later evolution in the course of the disease. “Treating the motor component of Parkinson's disease, which is what we all do, does not appear to really do much for cognition and at times makes it worse,” Dr. Eidelberg said.

The researchers also prospectively computed PDCP expression for PD patients on and off treatment during consecutive days. “While the levodopa and deep brain stimulation were very helpful in the elevated PD-related pattern network, the same interventions in the same people had no real effect on PDCP,” he said. This finding implies that new therapies are needed to treat cognitive changes.

The data validate PDCP as a stable and reproducible imaging marker of cognitive function in PD. Unlike the PD motor-related pattern, the nonmotor pattern evolves slowly over time and its expression is not altered by therapeutic interventions targeting the motor manifestation of PD.

Metabolic decreases in the prefrontal/frontal cortex (in green; Brodmann areas 9, 46) and parietal cortex (Brodmann 7, 39, 40) typify PDCP for mild/moderate cognitive impairment. Courtesy Dr. David Eidelberg