Kerri Wachter

WASHINGTON — A procalcitonin-guided protocol can cut the duration of antibiotic use in patients with community-acquired pneumonia by roughly 50%, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Procalcitonin seems to be a more reliable parameter for the individual tailoring and discontinuation of antibiotics as compared with commonly and routinely used clinical and laboratory parameters,” said Dr. Mirjam Christ-Crain, an endocrinologist at the University Hospital Basel (Switzerland).

She and her colleagues proposed using procalcitonin as a biomarker to guide antibiotic treatment because the propeptide of calcitonin is increased with increasing severity of bacterial infection.

For this study, patients with community-acquired pneumonia (CAP) were randomized to receive therapy of standard duration (151 patients) or therapy whose duration was guided by procalcitonin (151 patients). Patients in both groups averaged age 70 years. Only 20% had antibiotic pretreatment. Most patients in both groups had comorbidities. More than two-thirds of patients had severe or very severe pneumonia.

Among those in the procalcitonin group, patients with levels greater than 0.25 mcg/L were started on antibiotic therapy. Those with levels of 0.25 mcg/L or less were not given antibiotics.

Procalcitonin measurements were performed on all patients on days 0, 2, 4, 6, and 8, though the results were available only for those in the procalcitonin group. The decision to continue or discontinue antibiotic therapy in the procalcitonin group was based on the cutoff levels described above. Follow-up, including a chest x-ray, was performed at 4–6 weeks. In patients with clinical uncertainty, there was follow-up remeasurement of procalcitonin in 6 hours.

Patients in the standard therapy group received antibiotics initially, and almost all of them were on antibiotics for more than 8 days. In comparison, only 85% of those in the procalcitonin group initially received antibiotics. In this group, “only about 50% had antibiotics for more than 4 days and about 30% for more than 6 days,” Dr. Christ-Crain said.

Patients in the procalcitonin group received antibiotics for an average of 6 days, compared with 13 days for the standard therapy group. “This is a highly significant reduction of antibiotic use and antibiotic duration,” said Dr. Christ-Crain, at the meeting sponsored by the American Society for Microbiology.

Clinical outcomes—as assessed by a visual analog scale and clinical parameters such as temperature, oxygen saturation, and pulse rate—were similar in both groups. Laboratory outcomes—C-reactive protein and procalcitonin levels in the normal reference ranges—assessed at 4–6 weeks were also similar.

Most experts recommend a 10–14-day course of antibiotic therapy to treat CAP, but the optimal duration is unknown. “In our opinion, the correct duration of antibiotics varies from patient to patient,” Dr. Christ-Crain said.

New tests for the determination of procalcitonin levels have improved sensitivity, enabling physicians to distinguish clinically relevant bacterial infections from other infections.

WASHINGTON — A procalcitonin-guided protocol can cut the duration of antibiotic use in patients with community-acquired pneumonia by roughly 50%, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Procalcitonin seems to be a more reliable parameter for the individual tailoring and discontinuation of antibiotics as compared with commonly and routinely used clinical and laboratory parameters,” said Dr. Mirjam Christ-Crain, an endocrinologist at the University Hospital Basel (Switzerland).

She and her colleagues proposed using procalcitonin as a biomarker to guide antibiotic treatment because the propeptide of calcitonin is increased with increasing severity of bacterial infection.

For this study, patients with community-acquired pneumonia (CAP) were randomized to receive therapy of standard duration (151 patients) or therapy whose duration was guided by procalcitonin (151 patients). Patients in both groups averaged age 70 years. Only 20% had antibiotic pretreatment. Most patients in both groups had comorbidities. More than two-thirds of patients had severe or very severe pneumonia.

Among those in the procalcitonin group, patients with levels greater than 0.25 mcg/L were started on antibiotic therapy. Those with levels of 0.25 mcg/L or less were not given antibiotics.

Procalcitonin measurements were performed on all patients on days 0, 2, 4, 6, and 8, though the results were available only for those in the procalcitonin group. The decision to continue or discontinue antibiotic therapy in the procalcitonin group was based on the cutoff levels described above. Follow-up, including a chest x-ray, was performed at 4–6 weeks. In patients with clinical uncertainty, there was follow-up remeasurement of procalcitonin in 6 hours.

Patients in the standard therapy group received antibiotics initially, and almost all of them were on antibiotics for more than 8 days. In comparison, only 85% of those in the procalcitonin group initially received antibiotics. In this group, “only about 50% had antibiotics for more than 4 days and about 30% for more than 6 days,” Dr. Christ-Crain said.

Patients in the procalcitonin group received antibiotics for an average of 6 days, compared with 13 days for the standard therapy group. “This is a highly significant reduction of antibiotic use and antibiotic duration,” said Dr. Christ-Crain, at the meeting sponsored by the American Society for Microbiology.

Clinical outcomes—as assessed by a visual analog scale and clinical parameters such as temperature, oxygen saturation, and pulse rate—were similar in both groups. Laboratory outcomes—C-reactive protein and procalcitonin levels in the normal reference ranges—assessed at 4–6 weeks were also similar.

Most experts recommend a 10–14-day course of antibiotic therapy to treat CAP, but the optimal duration is unknown. “In our opinion, the correct duration of antibiotics varies from patient to patient,” Dr. Christ-Crain said.

New tests for the determination of procalcitonin levels have improved sensitivity, enabling physicians to distinguish clinically relevant bacterial infections from other infections.

WASHINGTON — A procalcitonin-guided protocol can cut the duration of antibiotic use in patients with community-acquired pneumonia by roughly 50%, according to data presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Procalcitonin seems to be a more reliable parameter for the individual tailoring and discontinuation of antibiotics as compared with commonly and routinely used clinical and laboratory parameters,” said Dr. Mirjam Christ-Crain, an endocrinologist at the University Hospital Basel (Switzerland).

She and her colleagues proposed using procalcitonin as a biomarker to guide antibiotic treatment because the propeptide of calcitonin is increased with increasing severity of bacterial infection.

For this study, patients with community-acquired pneumonia (CAP) were randomized to receive therapy of standard duration (151 patients) or therapy whose duration was guided by procalcitonin (151 patients). Patients in both groups averaged age 70 years. Only 20% had antibiotic pretreatment. Most patients in both groups had comorbidities. More than two-thirds of patients had severe or very severe pneumonia.

Among those in the procalcitonin group, patients with levels greater than 0.25 mcg/L were started on antibiotic therapy. Those with levels of 0.25 mcg/L or less were not given antibiotics.

Procalcitonin measurements were performed on all patients on days 0, 2, 4, 6, and 8, though the results were available only for those in the procalcitonin group. The decision to continue or discontinue antibiotic therapy in the procalcitonin group was based on the cutoff levels described above. Follow-up, including a chest x-ray, was performed at 4–6 weeks. In patients with clinical uncertainty, there was follow-up remeasurement of procalcitonin in 6 hours.

Patients in the standard therapy group received antibiotics initially, and almost all of them were on antibiotics for more than 8 days. In comparison, only 85% of those in the procalcitonin group initially received antibiotics. In this group, “only about 50% had antibiotics for more than 4 days and about 30% for more than 6 days,” Dr. Christ-Crain said.

Patients in the procalcitonin group received antibiotics for an average of 6 days, compared with 13 days for the standard therapy group. “This is a highly significant reduction of antibiotic use and antibiotic duration,” said Dr. Christ-Crain, at the meeting sponsored by the American Society for Microbiology.

Clinical outcomes—as assessed by a visual analog scale and clinical parameters such as temperature, oxygen saturation, and pulse rate—were similar in both groups. Laboratory outcomes—C-reactive protein and procalcitonin levels in the normal reference ranges—assessed at 4–6 weeks were also similar.

Most experts recommend a 10–14-day course of antibiotic therapy to treat CAP, but the optimal duration is unknown. “In our opinion, the correct duration of antibiotics varies from patient to patient,” Dr. Christ-Crain said.

New tests for the determination of procalcitonin levels have improved sensitivity, enabling physicians to distinguish clinically relevant bacterial infections from other infections.

Researchers with the Alz-heimer's Disease Neuro-imaging Initiative are recruiting 800 older adults to participate in a landmark study to identify biologic markers of memory decline and Alzheimer's disease.

The National Institutes of Health study is the most comprehensive effort to date to identify biochemical and brain imaging changes associated with memory decline. The study is expected to last 5 years.

The researchers are seeking adults aged 55–90 years, who are in good general health with no memory problems or who are in good general health but have memory problems/concerns or a diagnosis of early Alzheimer's disease (AD). The researchers expect to enroll 400 patients with mild cognitive impairment (MCI), 200 cognitively normal controls, and 200 with early AD.

The researchers will be performing serial MRI and PET scans, and measuring various biologic compounds in the blood, cerebrospinal fluid, and urine. The participants will also undergo clinical and neuropsychologic assessments to track MCI and early AD progression. Healthy volunteers and patients with MCI will be followed for 3 years, while those with early AD will be followed for 2 years. Patients will be evaluated at 58 study sites in the United States and Canada.

For more information about participating in the study and to obtain a list of sites, contact the National Institute on Aging's Alzheimer's Disease Education and Referral Center by visiting www.alzheimers.org/imagine

Researchers with the Alz-heimer's Disease Neuro-imaging Initiative are recruiting 800 older adults to participate in a landmark study to identify biologic markers of memory decline and Alzheimer's disease.

The National Institutes of Health study is the most comprehensive effort to date to identify biochemical and brain imaging changes associated with memory decline. The study is expected to last 5 years.

The researchers are seeking adults aged 55–90 years, who are in good general health with no memory problems or who are in good general health but have memory problems/concerns or a diagnosis of early Alzheimer's disease (AD). The researchers expect to enroll 400 patients with mild cognitive impairment (MCI), 200 cognitively normal controls, and 200 with early AD.

The researchers will be performing serial MRI and PET scans, and measuring various biologic compounds in the blood, cerebrospinal fluid, and urine. The participants will also undergo clinical and neuropsychologic assessments to track MCI and early AD progression. Healthy volunteers and patients with MCI will be followed for 3 years, while those with early AD will be followed for 2 years. Patients will be evaluated at 58 study sites in the United States and Canada.

For more information about participating in the study and to obtain a list of sites, contact the National Institute on Aging's Alzheimer's Disease Education and Referral Center by visiting www.alzheimers.org/imagine

Researchers with the Alz-heimer's Disease Neuro-imaging Initiative are recruiting 800 older adults to participate in a landmark study to identify biologic markers of memory decline and Alzheimer's disease.

The National Institutes of Health study is the most comprehensive effort to date to identify biochemical and brain imaging changes associated with memory decline. The study is expected to last 5 years.

The researchers are seeking adults aged 55–90 years, who are in good general health with no memory problems or who are in good general health but have memory problems/concerns or a diagnosis of early Alzheimer's disease (AD). The researchers expect to enroll 400 patients with mild cognitive impairment (MCI), 200 cognitively normal controls, and 200 with early AD.

The researchers will be performing serial MRI and PET scans, and measuring various biologic compounds in the blood, cerebrospinal fluid, and urine. The participants will also undergo clinical and neuropsychologic assessments to track MCI and early AD progression. Healthy volunteers and patients with MCI will be followed for 3 years, while those with early AD will be followed for 2 years. Patients will be evaluated at 58 study sites in the United States and Canada.

For more information about participating in the study and to obtain a list of sites, contact the National Institute on Aging's Alzheimer's Disease Education and Referral Center by visiting www.alzheimers.org/imagine

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — For those who are thinking about going into the medical spa business, Dr. Mitchel P. Goldman, a dermatologist in private practice in La Jolla, Calif., named the essential services to offer:

▸ Intense pulsed light. "If you can only buy one machine, intense pulsed light is the machine that you need to purchase because it can do so much," Dr. Goldman said.

Intense pulsed light (IPL) devices can be used for hair removal, dyspigmentation, and photodamage. The device can also be used in conjunction with levulinic acid to treat patients with actinic keratoses. He estimated that IPL machines cost between $40,000 and $100,000.

▸ Laser hair removal. The next procedure to consider adding to a medical spa practice is laser hair removal. "Laser hair removal is also a huge potential business," Dr. Goldman said.

He noted that there are good opportunities to save money on used laser hair removal equipment. New hair removal laser systems range between $60,000 and $150,000.

▸ Long- and short-pulse lasers. "If you want to go to the next level, we still use our erbium: yttrium aluminum garnet (Er:YAG) laser—both long and short pulse—to do full face resurfacing," said Dr. Goldman.

This is a procedure that must be done by a physician and not a nurse or nurse-practitioner, he cautioned. Expect to pay about $60,000 for a long- or short-pulse Er:YAG laser.

▸ Laser cellulite treatment. This procedure is becoming more popular. There are two lasers available for cellulite treatment: the Cynosure TriActive and the Syneron VelaSmooth. The TriActive system costs about $25,000 and the VelaSmooth system about $60,000. "These are incredibly profitable in our practice," Dr. Goldman said.

▸ Pigmentation. "We also have an alexandrite and a long-pulse YAG laser that we use because I believe that if you're going to treat a pigmented population, especially an African American population, you must have a 1,064-nm long-pulse YAG laser," he said. For any other population, a diode or alexandrite laser should work.

Dr. Goldman has financial relationships with STD Pharmaceutical, BTG plc., and CoolTouch.

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

ORLANDO — One way to achieve a more youthful appearance may be to restore volume around the eyes and mouth rather than simply remove excess skin, said Dr. Mark Berman at the annual meeting of the American Academy of Cosmetic Surgery.

"The anterior position of the skin on the face is the single most neglected aspect of aging," said Dr. Berman, a cosmetic surgeon in Santa Monica, Calif. Like a beach ball that has started to deflate, skin starts to sag as it ages. The answer, he suggested, is not to remove excess skin but to "blow it back up." Autologous fat transfer allows physicians to do just that.

"Here's the key: Think three-dimensional. The whole key to rejuvenation is restoring contour," he said. The easiest way to do that is to put back what is missing—fat.

Although it doesn't really matter where fat is harvested, the first choice for a donor site is anyplace where the patient desires to be rid of a little fat, Dr. Berman said in an interview. For most women, this is the upper posterior hip, the lateral thigh, or abdomen. Men usually prefer to use the abdomen or flanks as donor sites.

For fat harvesting, he uses local anesthesia, injecting just under the skin and then deeper into the fat. Tumescent anesthesia is an option, though he does not use it. He removes 60–120 cc of fat, depending on how much is available at the site. "You just have to take out as much as you can without causing much of a defect," he said.

Dr. Berman has been using the LipiVage system made by Genesis Biosystems to harvest and transfer fat for the past 6 months with very good results. He reported that he has no financial interest in the company. The system eliminates the need to centrifuge, decant, or expose fat cells to additional handling.

Fat is withdrawn from a donor site elsewhere on the body, and the system cleans and concentrates the fat cells. The resulting canister of fat cells is ready for transfer.

Before he began using this system, Dr. Berman harvested fat in a syringe, adding 1 cc of albumin to help increase the cellular oncotic pressure. This step draws fluid out of the cells, returning them to a more natural physiologic state. This step is more important when tumescent anesthesia is used. It's also helpful to centrifuge the fat to reduce the amount of fluid in the aliquots for injection if tumescent anesthesia is used.

Dr. Berman uses injectors made by Tulip Products because they are a little bit smaller. "I think it's a little less traumatic," he said. Dr. Berman reported that he has no financial interest in Tulip Products.

The key to injecting is to use the palm of the hand to inject rather than the thumb. "You've got to have a lot of control with the syringe. So you use the back [end] of your hand to slowly … put in tiny pellets of fat, so you get a better chance of revascularization," Dr. Berman said.

For the eye area, inject into the medial and lateral aspects of the brow, the temporal area, and the cheek. The amount of fat injected depends on the patient and the area being treated. Dr. Berman typically uses 1–5 cc for the upper lid/brow, 3–6 cc for the lower lid/cheek, 4–6 cc for the perioral area, up to 2 cc for the lips, and 3–5 cc for the mandible. "The round contour is really the key to a youthful eye," he said.

He advises physicians to think globally, not focally. Don't think about filling just one or two lines—fill the entire area. Also, if a patient is unsure, use saline solution to test how the final procedure will look.

Following the procedure, patients may use ice if they want. They should keep activities light for the first week, then gradually resume exercising. Patients should limit jarring motions to minimize trauma.

Three eyelid operations failed to remove the defect notable on the left lower lid (left photo). Fat grafting (right photo) restored the cheeks and lids to their natural contours. Photos courtesy Dr. Mark Berman

Patients taking a glucocorticoid have a nearly fivefold increased risk of developing tuberculosis, independent of other risk factors.

“Our results suggest that glucocorticoid use is associated with a substantially increased risk of developing tuberculosis and that the risk increases with increasing daily dose,” said Susan S. Jick, Sc.D., of Boston University, and her colleagues.

Although chronic corticosteroid use is common in patients with rheumatic diseases, the number of such patients in the study population was too small to say definitely if use of corticosteroids specifically for arthritis and other rheumatic diseases was associated with an increased risk for TB.

Low body mass index (BMI), diabetes, current smoking, and obstructive pulmonary disorders were also determined to be important risk factors for tuberculosis in a review of 497 new cases of tuberculosis and 1,966 matched controls during the period 1990–2001 (Arthritis Rheum. 2006;55:19–26).

The researchers based their study on data available from the U.K.-based General Practice Research Database. Started in 1987, the validated computerized medical record system includes more than 3 million people enrolled with selected general practitioners. Participants had a first-time diagnosis of tuberculosis followed by treatment with at least three different antituberculosis medications for at least 6 months.

As many as four control subjects were matched to each patient based on age, gender, practice attended, and the patient's index date, along with time of visit.

Assessment of glucocorticoid use was based on prescription data. Patients were classified as currently exposed if they had received a prescription for any oral glucocorticoid and if the supply had lasted until within 120 days prior to the index date. Recent exposure was defined as use ending 121–180 days before the index date. All other use more than 180 days prior was considered past use.

The researchers also assessed current exposure to antirheumatic drugs or immunosuppressants and the presence of pulmonary disorders, rheumatic disorders, inflammatory bowel diseases, dermatitis, silicosis, renal failure, gastrectomy, and jejunoileal bypass surgery (diagnosed prior to the index date).

Patients currently using corticosteroids were 4.9 times more likely to develop tuberculosis than nonusers, even after adjustment for BMI, smoking, disease-modifying antirheumatic drug use, and history of diabetes and pulmonary disease. The risk for tuberculosis remained higher (OR 4.3) in patients who had recently stopped using corticosteroids.

First-time users were 3.2 times more likely to get tuberculosis than were never users. Patients with longer-term use, extending over two to nine consecutive prescriptions, saw their risk increase sevenfold.

The effect of corticosteroid use on risk for TB increased with increasing dose. The OR was 2.3 in people taking daily doses of prednisone equivalents less than 7.5 mg daily (physiologic) versus those taking supraphysiologic doses of 7.5 mg or more daily (OR 7.0, based on the highest daily dosage received by current users).

Both the American Thoracic Society and the Centers for Disease Control and Prevention agree that more than 15 mg/day of prednisone or its equivalent administered for 1 month or longer is a risk factor for tuberculosis. In light of this, the researchers evaluated the impact of daily dosage using this cutoff. The adjusted odds ratio was 2.8 for those using less than 15 mg of prednisone equivalents per day; those using 15 mg of prednisone equivalents per day or more had an adjusted odds ratio of 7.7.

We found that current smoking was associated with a 60% increased risk of tuberculosis. Although this effect is relatively low, because smoking is prevalent in this study population, 17% of all cases are attributable to smoking, compared with only 8% of cases attributable to glucocorticoid use in this population,” the researchers said. The odds ratio for past smokers was not significant.

Those with a BMI less than 20 kg/m

A diagnosis of rheumatic disease and use of antirheumatic agents are purported to be risk factors for tuberculosis as well.

However, the number of patients taking antirheumatic drugs in this analysis was low; only 12 patients were currently exposed. Overall, 17 participants (cases and controls) had rheumatoid arthritis, 1 had lupus, 12 had polymyalgia rheumatica, and 7 had arteritis. “Despite the large number of tuberculosis cases in this study, the prevalence of antirheumatic agent use was low,” and thus independent effects for patients on antirheumatics could not be assessed reliably, the researchers noted.

Patients taking a glucocorticoid have a nearly fivefold increased risk of developing tuberculosis, independent of other risk factors.

“Our results suggest that glucocorticoid use is associated with a substantially increased risk of developing tuberculosis and that the risk increases with increasing daily dose,” said Susan S. Jick, Sc.D., of Boston University, and her colleagues.

Although chronic corticosteroid use is common in patients with rheumatic diseases, the number of such patients in the study population was too small to say definitely if use of corticosteroids specifically for arthritis and other rheumatic diseases was associated with an increased risk for TB.

Low body mass index (BMI), diabetes, current smoking, and obstructive pulmonary disorders were also determined to be important risk factors for tuberculosis in a review of 497 new cases of tuberculosis and 1,966 matched controls during the period 1990–2001 (Arthritis Rheum. 2006;55:19–26).

The researchers based their study on data available from the U.K.-based General Practice Research Database. Started in 1987, the validated computerized medical record system includes more than 3 million people enrolled with selected general practitioners. Participants had a first-time diagnosis of tuberculosis followed by treatment with at least three different antituberculosis medications for at least 6 months.

As many as four control subjects were matched to each patient based on age, gender, practice attended, and the patient's index date, along with time of visit.

Assessment of glucocorticoid use was based on prescription data. Patients were classified as currently exposed if they had received a prescription for any oral glucocorticoid and if the supply had lasted until within 120 days prior to the index date. Recent exposure was defined as use ending 121–180 days before the index date. All other use more than 180 days prior was considered past use.

The researchers also assessed current exposure to antirheumatic drugs or immunosuppressants and the presence of pulmonary disorders, rheumatic disorders, inflammatory bowel diseases, dermatitis, silicosis, renal failure, gastrectomy, and jejunoileal bypass surgery (diagnosed prior to the index date).

Patients currently using corticosteroids were 4.9 times more likely to develop tuberculosis than nonusers, even after adjustment for BMI, smoking, disease-modifying antirheumatic drug use, and history of diabetes and pulmonary disease. The risk for tuberculosis remained higher (OR 4.3) in patients who had recently stopped using corticosteroids.

First-time users were 3.2 times more likely to get tuberculosis than were never users. Patients with longer-term use, extending over two to nine consecutive prescriptions, saw their risk increase sevenfold.

The effect of corticosteroid use on risk for TB increased with increasing dose. The OR was 2.3 in people taking daily doses of prednisone equivalents less than 7.5 mg daily (physiologic) versus those taking supraphysiologic doses of 7.5 mg or more daily (OR 7.0, based on the highest daily dosage received by current users).

Both the American Thoracic Society and the Centers for Disease Control and Prevention agree that more than 15 mg/day of prednisone or its equivalent administered for 1 month or longer is a risk factor for tuberculosis. In light of this, the researchers evaluated the impact of daily dosage using this cutoff. The adjusted odds ratio was 2.8 for those using less than 15 mg of prednisone equivalents per day; those using 15 mg of prednisone equivalents per day or more had an adjusted odds ratio of 7.7.

We found that current smoking was associated with a 60% increased risk of tuberculosis. Although this effect is relatively low, because smoking is prevalent in this study population, 17% of all cases are attributable to smoking, compared with only 8% of cases attributable to glucocorticoid use in this population,” the researchers said. The odds ratio for past smokers was not significant.

Those with a BMI less than 20 kg/m

A diagnosis of rheumatic disease and use of antirheumatic agents are purported to be risk factors for tuberculosis as well.

However, the number of patients taking antirheumatic drugs in this analysis was low; only 12 patients were currently exposed. Overall, 17 participants (cases and controls) had rheumatoid arthritis, 1 had lupus, 12 had polymyalgia rheumatica, and 7 had arteritis. “Despite the large number of tuberculosis cases in this study, the prevalence of antirheumatic agent use was low,” and thus independent effects for patients on antirheumatics could not be assessed reliably, the researchers noted.

Patients taking a glucocorticoid have a nearly fivefold increased risk of developing tuberculosis, independent of other risk factors.

“Our results suggest that glucocorticoid use is associated with a substantially increased risk of developing tuberculosis and that the risk increases with increasing daily dose,” said Susan S. Jick, Sc.D., of Boston University, and her colleagues.

Although chronic corticosteroid use is common in patients with rheumatic diseases, the number of such patients in the study population was too small to say definitely if use of corticosteroids specifically for arthritis and other rheumatic diseases was associated with an increased risk for TB.

Low body mass index (BMI), diabetes, current smoking, and obstructive pulmonary disorders were also determined to be important risk factors for tuberculosis in a review of 497 new cases of tuberculosis and 1,966 matched controls during the period 1990–2001 (Arthritis Rheum. 2006;55:19–26).

The researchers based their study on data available from the U.K.-based General Practice Research Database. Started in 1987, the validated computerized medical record system includes more than 3 million people enrolled with selected general practitioners. Participants had a first-time diagnosis of tuberculosis followed by treatment with at least three different antituberculosis medications for at least 6 months.

As many as four control subjects were matched to each patient based on age, gender, practice attended, and the patient's index date, along with time of visit.

Assessment of glucocorticoid use was based on prescription data. Patients were classified as currently exposed if they had received a prescription for any oral glucocorticoid and if the supply had lasted until within 120 days prior to the index date. Recent exposure was defined as use ending 121–180 days before the index date. All other use more than 180 days prior was considered past use.

The researchers also assessed current exposure to antirheumatic drugs or immunosuppressants and the presence of pulmonary disorders, rheumatic disorders, inflammatory bowel diseases, dermatitis, silicosis, renal failure, gastrectomy, and jejunoileal bypass surgery (diagnosed prior to the index date).

Patients currently using corticosteroids were 4.9 times more likely to develop tuberculosis than nonusers, even after adjustment for BMI, smoking, disease-modifying antirheumatic drug use, and history of diabetes and pulmonary disease. The risk for tuberculosis remained higher (OR 4.3) in patients who had recently stopped using corticosteroids.

First-time users were 3.2 times more likely to get tuberculosis than were never users. Patients with longer-term use, extending over two to nine consecutive prescriptions, saw their risk increase sevenfold.

The effect of corticosteroid use on risk for TB increased with increasing dose. The OR was 2.3 in people taking daily doses of prednisone equivalents less than 7.5 mg daily (physiologic) versus those taking supraphysiologic doses of 7.5 mg or more daily (OR 7.0, based on the highest daily dosage received by current users).

Both the American Thoracic Society and the Centers for Disease Control and Prevention agree that more than 15 mg/day of prednisone or its equivalent administered for 1 month or longer is a risk factor for tuberculosis. In light of this, the researchers evaluated the impact of daily dosage using this cutoff. The adjusted odds ratio was 2.8 for those using less than 15 mg of prednisone equivalents per day; those using 15 mg of prednisone equivalents per day or more had an adjusted odds ratio of 7.7.

We found that current smoking was associated with a 60% increased risk of tuberculosis. Although this effect is relatively low, because smoking is prevalent in this study population, 17% of all cases are attributable to smoking, compared with only 8% of cases attributable to glucocorticoid use in this population,” the researchers said. The odds ratio for past smokers was not significant.

Those with a BMI less than 20 kg/m

A diagnosis of rheumatic disease and use of antirheumatic agents are purported to be risk factors for tuberculosis as well.

However, the number of patients taking antirheumatic drugs in this analysis was low; only 12 patients were currently exposed. Overall, 17 participants (cases and controls) had rheumatoid arthritis, 1 had lupus, 12 had polymyalgia rheumatica, and 7 had arteritis. “Despite the large number of tuberculosis cases in this study, the prevalence of antirheumatic agent use was low,” and thus independent effects for patients on antirheumatics could not be assessed reliably, the researchers noted.

The Food and Drug Administration is warning physicians that the blood-loss prevention drug Trasylol (aprotinin injection) has been linked to higher risks of kidney problems, heart attacks, and strokes in patients who undergo coronary artery bypass graft surgery.

Aprotinin is the only product approved for the prevention of perioperative blood loss and of the need for blood transfusion during coronary artery bypass graft surgery.

In particular, physicians should be aware of the following:

▸ When using aprotinin, physicians should carefully monitor patients for the occurrence of toxicity—particularly to the kidneys, heart, or central nervous system—and promptly report adverse event information to the drug's manufacturer (Bayer AG) or to the FDA's Medwatch program.

▸ Physicians should consider limiting use of the drug to situations in which the clinical benefit of reduced blood loss is essential to management of the condition and outweighs the risks.

▸ The FDA is working with the manufacturer to examine the safety and benefits of the drug in light of recent data.

▸ Physicians should discuss all major risks for heart bypass surgery with their patients, including the risks for bleeding and available means of lessening the risk.

The FDA is currently evaluating data from scientific literature and reports submitted to the MedWatch program to determine if label changes or other actions are warranted. The agency also anticipates discussing the existing data about the risks and benefits of the drug during an advisory committee meeting to be held some time in 2006. The committee also will consider if additional safety measures need to be taken.

To report adverse events to the MedWatch program, call 800-332-1088 or go to the program Web site, www.fda.gov/medwatchwww.fda.gov/cder/drug/infopage/aprotinin/default.htm

The Food and Drug Administration is warning physicians that the blood-loss prevention drug Trasylol (aprotinin injection) has been linked to higher risks of kidney problems, heart attacks, and strokes in patients who undergo coronary artery bypass graft surgery.

Aprotinin is the only product approved for the prevention of perioperative blood loss and of the need for blood transfusion during coronary artery bypass graft surgery.

In particular, physicians should be aware of the following:

▸ When using aprotinin, physicians should carefully monitor patients for the occurrence of toxicity—particularly to the kidneys, heart, or central nervous system—and promptly report adverse event information to the drug's manufacturer (Bayer AG) or to the FDA's Medwatch program.

▸ Physicians should consider limiting use of the drug to situations in which the clinical benefit of reduced blood loss is essential to management of the condition and outweighs the risks.

▸ The FDA is working with the manufacturer to examine the safety and benefits of the drug in light of recent data.

▸ Physicians should discuss all major risks for heart bypass surgery with their patients, including the risks for bleeding and available means of lessening the risk.

The FDA is currently evaluating data from scientific literature and reports submitted to the MedWatch program to determine if label changes or other actions are warranted. The agency also anticipates discussing the existing data about the risks and benefits of the drug during an advisory committee meeting to be held some time in 2006. The committee also will consider if additional safety measures need to be taken.

To report adverse events to the MedWatch program, call 800-332-1088 or go to the program Web site, www.fda.gov/medwatchwww.fda.gov/cder/drug/infopage/aprotinin/default.htm

The Food and Drug Administration is warning physicians that the blood-loss prevention drug Trasylol (aprotinin injection) has been linked to higher risks of kidney problems, heart attacks, and strokes in patients who undergo coronary artery bypass graft surgery.

Aprotinin is the only product approved for the prevention of perioperative blood loss and of the need for blood transfusion during coronary artery bypass graft surgery.

In particular, physicians should be aware of the following:

▸ When using aprotinin, physicians should carefully monitor patients for the occurrence of toxicity—particularly to the kidneys, heart, or central nervous system—and promptly report adverse event information to the drug's manufacturer (Bayer AG) or to the FDA's Medwatch program.

▸ Physicians should consider limiting use of the drug to situations in which the clinical benefit of reduced blood loss is essential to management of the condition and outweighs the risks.

▸ The FDA is working with the manufacturer to examine the safety and benefits of the drug in light of recent data.

▸ Physicians should discuss all major risks for heart bypass surgery with their patients, including the risks for bleeding and available means of lessening the risk.

The FDA is currently evaluating data from scientific literature and reports submitted to the MedWatch program to determine if label changes or other actions are warranted. The agency also anticipates discussing the existing data about the risks and benefits of the drug during an advisory committee meeting to be held some time in 2006. The committee also will consider if additional safety measures need to be taken.

To report adverse events to the MedWatch program, call 800-332-1088 or go to the program Web site, www.fda.gov/medwatchwww.fda.gov/cder/drug/infopage/aprotinin/default.htm

Surgical Site Infection Risk

Hypertension, obesity, diabetes, and increased ventilator use were significant risk factors for surgical site infections among cardiac surgery patients, Nandan Kumar reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

In the retrospective study of 199 patients who underwent coronary artery bypass or valve replacement surgery between January 2002 and December 2004, 56 (84%) of the 67 patients with gram-negative surgical site infections (SSIs) had hypertension, compared with 96 (70%) of 132 uninfected patients in a multivariate analysis.

In addition, 58% of infected patients were obese, defined as having a BMI of at least 30 kg/m

The average patient age was 65 years, 68% were men, and 71% were white, wrote Mr. Kumar, of the University of Houston College of Pharmacy, and his colleagues. Hospital stays and postoperative stays in the intensive care unit were an average of 6 days and 5 days longer, respectively, for infected patients than for uninfected patients. However, 90-day mortality rates were not significantly affected by gram-negative SSIs, the researchers noted.

Hepatitis B Test Kit Recalled

Ortho-Clinical Diagnostics Inc. and the Food and Drug Administration have issued a class I recall of the VITROS immunodiagnostic HBsAg confirmatory kit because of false-negative results in the confirmation of the presence of hepatitis B surface antigen in human blood and plasma.

An unknown component in the diluting solution that is used to test blood and serum samples may produce “not confirmed” results for samples that are found to be positive with the initial test, resulting in false negatives.

False-negative results may prevent some patients who are infected with or carrying the virus from receiving necessary treatment. The possibility of false-negative results is of particular concern for pregnant women. “When their fetuses are born, they will be presumed negative, and [will not be] treated with the hepatitis B immunoglobulin and hepatitis B vaccine. Such infants have a 90% chance of progressing to chronic hepatitis B virus infection, resulting in possible liver transplantation or early death,” according to the FDA.

In mid-December, the company sent letters to medical facilities, testing laboratories, and public health agencies instructing customers to discontinue use of the kits and discard any remaining inventory. Previously reported results should be reviewed. Those with questions should contact Ortho-Clinical Diagnostics' Judy M. Strzepek by calling 908-218-8524.

A class I recall is the most serious type of FDA recall. It involves situations in which there is a reasonable probability that use of the product will cause serious injury or death.

Catheters and Bloodstream Infections

Peripherally inserted central catheters have a lower incidence of infection than do Hickman catheters, but they become infected more quickly, Dr. Alfred E. Bacon III reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

During a 2-year study conducted by Dr. Bacon and his colleagues at the Christiana Care Health System in Newark, Del., 36 (1.7%) of 2,096 peripherally inserted central catheters (PICCs) in 1,834 patients caused catheter-related bloodstream infections, compared with 43 (9.2%) of 468 Hickman catheters in 383 patients.

A total of 91 pathogens were isolated, including 42 gram-negative rods, 31 gram-positive organisms, 11 yeast, and 7 unknown, unclassified, or miscellaneous pathogens.

Catheter-related bloodstream infections were defined in three ways: positive blood cultures matching the catheter tip culture on removal, multiple positive blood cultures and response to IV antibiotics without another identifiable infection source, and multiple positive blood cultures after line removal in the absence of another identifiable infection source. Catheter care techniques included changing the dressing every 7 days and cleaning and examining the site for infection.

A higher infection rate with Hickman catheters may reflect their use in patients with more complications for longer periods of time, Dr. Bacon and his colleagues wrote. The average time to infection was 82 days for Hickman catheters, compared with 43 days for PICCs. This time frame is typical for PICC use.

The investigators developed an infection control algorithm that included treatment with systemic antibiotics and catheter removal if the catheter was unsalvageable.

Surgical Site Infection Risk

Hypertension, obesity, diabetes, and increased ventilator use were significant risk factors for surgical site infections among cardiac surgery patients, Nandan Kumar reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

In the retrospective study of 199 patients who underwent coronary artery bypass or valve replacement surgery between January 2002 and December 2004, 56 (84%) of the 67 patients with gram-negative surgical site infections (SSIs) had hypertension, compared with 96 (70%) of 132 uninfected patients in a multivariate analysis.

In addition, 58% of infected patients were obese, defined as having a BMI of at least 30 kg/m

The average patient age was 65 years, 68% were men, and 71% were white, wrote Mr. Kumar, of the University of Houston College of Pharmacy, and his colleagues. Hospital stays and postoperative stays in the intensive care unit were an average of 6 days and 5 days longer, respectively, for infected patients than for uninfected patients. However, 90-day mortality rates were not significantly affected by gram-negative SSIs, the researchers noted.

Hepatitis B Test Kit Recalled

Ortho-Clinical Diagnostics Inc. and the Food and Drug Administration have issued a class I recall of the VITROS immunodiagnostic HBsAg confirmatory kit because of false-negative results in the confirmation of the presence of hepatitis B surface antigen in human blood and plasma.

An unknown component in the diluting solution that is used to test blood and serum samples may produce “not confirmed” results for samples that are found to be positive with the initial test, resulting in false negatives.

False-negative results may prevent some patients who are infected with or carrying the virus from receiving necessary treatment. The possibility of false-negative results is of particular concern for pregnant women. “When their fetuses are born, they will be presumed negative, and [will not be] treated with the hepatitis B immunoglobulin and hepatitis B vaccine. Such infants have a 90% chance of progressing to chronic hepatitis B virus infection, resulting in possible liver transplantation or early death,” according to the FDA.

In mid-December, the company sent letters to medical facilities, testing laboratories, and public health agencies instructing customers to discontinue use of the kits and discard any remaining inventory. Previously reported results should be reviewed. Those with questions should contact Ortho-Clinical Diagnostics' Judy M. Strzepek by calling 908-218-8524.

A class I recall is the most serious type of FDA recall. It involves situations in which there is a reasonable probability that use of the product will cause serious injury or death.

Catheters and Bloodstream Infections

Peripherally inserted central catheters have a lower incidence of infection than do Hickman catheters, but they become infected more quickly, Dr. Alfred E. Bacon III reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

During a 2-year study conducted by Dr. Bacon and his colleagues at the Christiana Care Health System in Newark, Del., 36 (1.7%) of 2,096 peripherally inserted central catheters (PICCs) in 1,834 patients caused catheter-related bloodstream infections, compared with 43 (9.2%) of 468 Hickman catheters in 383 patients.

A total of 91 pathogens were isolated, including 42 gram-negative rods, 31 gram-positive organisms, 11 yeast, and 7 unknown, unclassified, or miscellaneous pathogens.

Catheter-related bloodstream infections were defined in three ways: positive blood cultures matching the catheter tip culture on removal, multiple positive blood cultures and response to IV antibiotics without another identifiable infection source, and multiple positive blood cultures after line removal in the absence of another identifiable infection source. Catheter care techniques included changing the dressing every 7 days and cleaning and examining the site for infection.

A higher infection rate with Hickman catheters may reflect their use in patients with more complications for longer periods of time, Dr. Bacon and his colleagues wrote. The average time to infection was 82 days for Hickman catheters, compared with 43 days for PICCs. This time frame is typical for PICC use.

The investigators developed an infection control algorithm that included treatment with systemic antibiotics and catheter removal if the catheter was unsalvageable.

Surgical Site Infection Risk

Hypertension, obesity, diabetes, and increased ventilator use were significant risk factors for surgical site infections among cardiac surgery patients, Nandan Kumar reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

In the retrospective study of 199 patients who underwent coronary artery bypass or valve replacement surgery between January 2002 and December 2004, 56 (84%) of the 67 patients with gram-negative surgical site infections (SSIs) had hypertension, compared with 96 (70%) of 132 uninfected patients in a multivariate analysis.

In addition, 58% of infected patients were obese, defined as having a BMI of at least 30 kg/m

The average patient age was 65 years, 68% were men, and 71% were white, wrote Mr. Kumar, of the University of Houston College of Pharmacy, and his colleagues. Hospital stays and postoperative stays in the intensive care unit were an average of 6 days and 5 days longer, respectively, for infected patients than for uninfected patients. However, 90-day mortality rates were not significantly affected by gram-negative SSIs, the researchers noted.

Hepatitis B Test Kit Recalled

Ortho-Clinical Diagnostics Inc. and the Food and Drug Administration have issued a class I recall of the VITROS immunodiagnostic HBsAg confirmatory kit because of false-negative results in the confirmation of the presence of hepatitis B surface antigen in human blood and plasma.

An unknown component in the diluting solution that is used to test blood and serum samples may produce “not confirmed” results for samples that are found to be positive with the initial test, resulting in false negatives.

False-negative results may prevent some patients who are infected with or carrying the virus from receiving necessary treatment. The possibility of false-negative results is of particular concern for pregnant women. “When their fetuses are born, they will be presumed negative, and [will not be] treated with the hepatitis B immunoglobulin and hepatitis B vaccine. Such infants have a 90% chance of progressing to chronic hepatitis B virus infection, resulting in possible liver transplantation or early death,” according to the FDA.

In mid-December, the company sent letters to medical facilities, testing laboratories, and public health agencies instructing customers to discontinue use of the kits and discard any remaining inventory. Previously reported results should be reviewed. Those with questions should contact Ortho-Clinical Diagnostics' Judy M. Strzepek by calling 908-218-8524.

A class I recall is the most serious type of FDA recall. It involves situations in which there is a reasonable probability that use of the product will cause serious injury or death.

Catheters and Bloodstream Infections

Peripherally inserted central catheters have a lower incidence of infection than do Hickman catheters, but they become infected more quickly, Dr. Alfred E. Bacon III reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

During a 2-year study conducted by Dr. Bacon and his colleagues at the Christiana Care Health System in Newark, Del., 36 (1.7%) of 2,096 peripherally inserted central catheters (PICCs) in 1,834 patients caused catheter-related bloodstream infections, compared with 43 (9.2%) of 468 Hickman catheters in 383 patients.

A total of 91 pathogens were isolated, including 42 gram-negative rods, 31 gram-positive organisms, 11 yeast, and 7 unknown, unclassified, or miscellaneous pathogens.

Catheter-related bloodstream infections were defined in three ways: positive blood cultures matching the catheter tip culture on removal, multiple positive blood cultures and response to IV antibiotics without another identifiable infection source, and multiple positive blood cultures after line removal in the absence of another identifiable infection source. Catheter care techniques included changing the dressing every 7 days and cleaning and examining the site for infection.

A higher infection rate with Hickman catheters may reflect their use in patients with more complications for longer periods of time, Dr. Bacon and his colleagues wrote. The average time to infection was 82 days for Hickman catheters, compared with 43 days for PICCs. This time frame is typical for PICC use.

The investigators developed an infection control algorithm that included treatment with systemic antibiotics and catheter removal if the catheter was unsalvageable.

NASHVILLE, TENN. — A history of fracture in childhood and adolescence may be a marker for osteoporosis later in life, suggest study findings presented at the annual meeting of the American Society for Bone and Mineral Research.

Girls with fractures have lower gains in bone mineral density (BMD) and lower bone mineral mass at pubertal maturity, especially at sites containing predominantly trabecular bone, said Dr. Serge L. Ferrari, professor of medicine at the Service of Bone Diseases at the Geneva University Hospital.

The researchers followed 125 girls from prepuberty to pubertal maturity, assessing BMD using dual x-ray absorptiometry at both fractured and nonfractured sites including the ultradistal radius, proximal radius, femur trochanter, lumbar spine, femur neck, and femur diaphysis. Questionnaires were used to assess calcium intake, and both children and parents were interviewed to monitor for any accidents, falls, or fractures.

During an average of 8.5 years follow-up, 59 fractures occurred in 42 girls, 48% of the fractures involved the forearm and/or the wrist.

Before puberty and at the age of peak height velocity, BMD values at the proximal radius tended to be lower in girls with fractures. At pubertal maturity, BMD in girls with fractures was significantly lower at the ultradistal radius, femur trochanter, and lumbar spine. BMD at the femur neck and femur diaphysis were not significantly different between the two groups at pubertal maturity.

Girls with fractures also had significantly less BMD gain throughout puberty at the lumbar spine (−8%) and ultradistal radius (−12%), compared with those without a history of fracture. This trend almost reached significance at the femur trochanter and the proximal radius.

Using Cox proportional hazard models, the researchers identified four factors that were significantly associated with decreased hazard ratios for fractures: radial diaphysis BMD at baseline and BMD gain (over puberty) at the ultradistal radius, lumbar spine, or femur trochanter.

BMD measurements at all sites were highly correlated between baseline and pubertal maturity. There were also within-trait correlations between mature daughters and their mothers, yielding heritability estimates of 80%–90% for the hip, spine, and proximal radius. This suggests a strong genetic component for BMD.

Fractures are common in childhood and adolescence, with one in three girls and one in two boys having a traumatic fracture as they grow. Three-quarters of these fractures are in the upper limbs.

Studies have suggested there is underlying fragility involved in traumatic fractures of childhood and adolescence. The peak incidence of traumatic fractures coincides with the age of peak height velocity, the age at which longitudinal growth is fastest. And the age of peak height velocity precedes the age of peak bone mass velocity, when most bone mass is acquired, by about 1 year. The hypothesis follows that bone fragility at peak height velocity results from a transient deficit in bone mineral accrual relative to bone size.

NASHVILLE, TENN. — A history of fracture in childhood and adolescence may be a marker for osteoporosis later in life, suggest study findings presented at the annual meeting of the American Society for Bone and Mineral Research.

Girls with fractures have lower gains in bone mineral density (BMD) and lower bone mineral mass at pubertal maturity, especially at sites containing predominantly trabecular bone, said Dr. Serge L. Ferrari, professor of medicine at the Service of Bone Diseases at the Geneva University Hospital.

The researchers followed 125 girls from prepuberty to pubertal maturity, assessing BMD using dual x-ray absorptiometry at both fractured and nonfractured sites including the ultradistal radius, proximal radius, femur trochanter, lumbar spine, femur neck, and femur diaphysis. Questionnaires were used to assess calcium intake, and both children and parents were interviewed to monitor for any accidents, falls, or fractures.

During an average of 8.5 years follow-up, 59 fractures occurred in 42 girls, 48% of the fractures involved the forearm and/or the wrist.

Before puberty and at the age of peak height velocity, BMD values at the proximal radius tended to be lower in girls with fractures. At pubertal maturity, BMD in girls with fractures was significantly lower at the ultradistal radius, femur trochanter, and lumbar spine. BMD at the femur neck and femur diaphysis were not significantly different between the two groups at pubertal maturity.

Girls with fractures also had significantly less BMD gain throughout puberty at the lumbar spine (−8%) and ultradistal radius (−12%), compared with those without a history of fracture. This trend almost reached significance at the femur trochanter and the proximal radius.

Using Cox proportional hazard models, the researchers identified four factors that were significantly associated with decreased hazard ratios for fractures: radial diaphysis BMD at baseline and BMD gain (over puberty) at the ultradistal radius, lumbar spine, or femur trochanter.

BMD measurements at all sites were highly correlated between baseline and pubertal maturity. There were also within-trait correlations between mature daughters and their mothers, yielding heritability estimates of 80%–90% for the hip, spine, and proximal radius. This suggests a strong genetic component for BMD.

Fractures are common in childhood and adolescence, with one in three girls and one in two boys having a traumatic fracture as they grow. Three-quarters of these fractures are in the upper limbs.

Studies have suggested there is underlying fragility involved in traumatic fractures of childhood and adolescence. The peak incidence of traumatic fractures coincides with the age of peak height velocity, the age at which longitudinal growth is fastest. And the age of peak height velocity precedes the age of peak bone mass velocity, when most bone mass is acquired, by about 1 year. The hypothesis follows that bone fragility at peak height velocity results from a transient deficit in bone mineral accrual relative to bone size.

NASHVILLE, TENN. — A history of fracture in childhood and adolescence may be a marker for osteoporosis later in life, suggest study findings presented at the annual meeting of the American Society for Bone and Mineral Research.

Girls with fractures have lower gains in bone mineral density (BMD) and lower bone mineral mass at pubertal maturity, especially at sites containing predominantly trabecular bone, said Dr. Serge L. Ferrari, professor of medicine at the Service of Bone Diseases at the Geneva University Hospital.

The researchers followed 125 girls from prepuberty to pubertal maturity, assessing BMD using dual x-ray absorptiometry at both fractured and nonfractured sites including the ultradistal radius, proximal radius, femur trochanter, lumbar spine, femur neck, and femur diaphysis. Questionnaires were used to assess calcium intake, and both children and parents were interviewed to monitor for any accidents, falls, or fractures.

During an average of 8.5 years follow-up, 59 fractures occurred in 42 girls, 48% of the fractures involved the forearm and/or the wrist.

Before puberty and at the age of peak height velocity, BMD values at the proximal radius tended to be lower in girls with fractures. At pubertal maturity, BMD in girls with fractures was significantly lower at the ultradistal radius, femur trochanter, and lumbar spine. BMD at the femur neck and femur diaphysis were not significantly different between the two groups at pubertal maturity.

Girls with fractures also had significantly less BMD gain throughout puberty at the lumbar spine (−8%) and ultradistal radius (−12%), compared with those without a history of fracture. This trend almost reached significance at the femur trochanter and the proximal radius.

Using Cox proportional hazard models, the researchers identified four factors that were significantly associated with decreased hazard ratios for fractures: radial diaphysis BMD at baseline and BMD gain (over puberty) at the ultradistal radius, lumbar spine, or femur trochanter.

BMD measurements at all sites were highly correlated between baseline and pubertal maturity. There were also within-trait correlations between mature daughters and their mothers, yielding heritability estimates of 80%–90% for the hip, spine, and proximal radius. This suggests a strong genetic component for BMD.

Fractures are common in childhood and adolescence, with one in three girls and one in two boys having a traumatic fracture as they grow. Three-quarters of these fractures are in the upper limbs.

Studies have suggested there is underlying fragility involved in traumatic fractures of childhood and adolescence. The peak incidence of traumatic fractures coincides with the age of peak height velocity, the age at which longitudinal growth is fastest. And the age of peak height velocity precedes the age of peak bone mass velocity, when most bone mass is acquired, by about 1 year. The hypothesis follows that bone fragility at peak height velocity results from a transient deficit in bone mineral accrual relative to bone size.

NASHVILLE, TENN. — Women with postmenopausal osteoporosis are no more likely to adhere to bisphosphonate therapy with weekly dosing than with daily dosing, according to data presented in a poster at the annual meeting of the American Society for Bone and Mineral Research.

In a retrospective study of 12,538 women with postmenopausal osteoporosis, risk of adherence failure did not differ between patients receiving weekly versus daily bisphosphonate therapy, according to Derek Weycker, Ph.D., of Policy Analysis Inc. in Brookline, Mass., and his colleagues.

The researchers reviewed integrated medical and outpatient pharmacy claims for women aged 45 years and older with postmenopausal osteoporosis from 30 U.S. health plans. Claims from January 1998 to December 2003 were included in the review.

Women were determined to have postmenopausal osteoporosis based on one or more medical claims with a corresponding diagnosis code. The women also had no evidence of secondary causes of osteoporosis. Patients were considered to have initiated therapy if their first corresponding prescription was preceded by a 6-month period of continuous health benefits without evidence of antiosteoporosis drug use.

Adherence was assessed on a daily basis from the date of therapy initiation through the date of a switch to another antiosteoporosis drug or formulation, date they left the plan, or Dec. 31, 2003—whichever came first. An adherence ratio was calculated by dividing the cumulative number of bisphosphonate therapy days by the number of elapsed calendar days (from therapy initiation). To calculate these measures, the researchers identified all outpatient pharmacy claims for weekly and daily bisphosphonate therapy based on corresponding codes from the National Drug Code system, arrayed them temporally based on dispensing dates, and assessed days of therapy supplied for each script based on the quantity of pills dispensed.

Within 6 months of initiating therapy, 57% of the 9,117 women on weekly therapy and 62% of the 3,421 women on daily therapy were considered to have adherence failure—defined as an adherence ratio less than 80%.

At 1 year, 66% of those on weekly therapy and 71% of those on daily therapy had adherence failure. At 2.5 years, the rates were 80% for weekly therapy and 82% for daily therapy.

After adjusting for age, fracture history, drug received, selected comorbid conditions, and selected concomitant medications, the two groups did not differ in risk of adherence failure. Risk of adherence failure was higher among women aged 65 years and older but was lower in those with a history of fracture.

The researchers did not assess adherence for specific drugs.

The research was funded by Amgen Inc., which is currently investigating a fully monoclonal antibody for the treatment of osteoporosis.

NASHVILLE, TENN. — Women with postmenopausal osteoporosis are no more likely to adhere to bisphosphonate therapy with weekly dosing than with daily dosing, according to data presented in a poster at the annual meeting of the American Society for Bone and Mineral Research.

In a retrospective study of 12,538 women with postmenopausal osteoporosis, risk of adherence failure did not differ between patients receiving weekly versus daily bisphosphonate therapy, according to Derek Weycker, Ph.D., of Policy Analysis Inc. in Brookline, Mass., and his colleagues.

The researchers reviewed integrated medical and outpatient pharmacy claims for women aged 45 years and older with postmenopausal osteoporosis from 30 U.S. health plans. Claims from January 1998 to December 2003 were included in the review.

Women were determined to have postmenopausal osteoporosis based on one or more medical claims with a corresponding diagnosis code. The women also had no evidence of secondary causes of osteoporosis. Patients were considered to have initiated therapy if their first corresponding prescription was preceded by a 6-month period of continuous health benefits without evidence of antiosteoporosis drug use.

Adherence was assessed on a daily basis from the date of therapy initiation through the date of a switch to another antiosteoporosis drug or formulation, date they left the plan, or Dec. 31, 2003—whichever came first. An adherence ratio was calculated by dividing the cumulative number of bisphosphonate therapy days by the number of elapsed calendar days (from therapy initiation). To calculate these measures, the researchers identified all outpatient pharmacy claims for weekly and daily bisphosphonate therapy based on corresponding codes from the National Drug Code system, arrayed them temporally based on dispensing dates, and assessed days of therapy supplied for each script based on the quantity of pills dispensed.

Within 6 months of initiating therapy, 57% of the 9,117 women on weekly therapy and 62% of the 3,421 women on daily therapy were considered to have adherence failure—defined as an adherence ratio less than 80%.

At 1 year, 66% of those on weekly therapy and 71% of those on daily therapy had adherence failure. At 2.5 years, the rates were 80% for weekly therapy and 82% for daily therapy.

After adjusting for age, fracture history, drug received, selected comorbid conditions, and selected concomitant medications, the two groups did not differ in risk of adherence failure. Risk of adherence failure was higher among women aged 65 years and older but was lower in those with a history of fracture.

The researchers did not assess adherence for specific drugs.

The research was funded by Amgen Inc., which is currently investigating a fully monoclonal antibody for the treatment of osteoporosis.

NASHVILLE, TENN. — Women with postmenopausal osteoporosis are no more likely to adhere to bisphosphonate therapy with weekly dosing than with daily dosing, according to data presented in a poster at the annual meeting of the American Society for Bone and Mineral Research.

In a retrospective study of 12,538 women with postmenopausal osteoporosis, risk of adherence failure did not differ between patients receiving weekly versus daily bisphosphonate therapy, according to Derek Weycker, Ph.D., of Policy Analysis Inc. in Brookline, Mass., and his colleagues.

The researchers reviewed integrated medical and outpatient pharmacy claims for women aged 45 years and older with postmenopausal osteoporosis from 30 U.S. health plans. Claims from January 1998 to December 2003 were included in the review.

Women were determined to have postmenopausal osteoporosis based on one or more medical claims with a corresponding diagnosis code. The women also had no evidence of secondary causes of osteoporosis. Patients were considered to have initiated therapy if their first corresponding prescription was preceded by a 6-month period of continuous health benefits without evidence of antiosteoporosis drug use.

Adherence was assessed on a daily basis from the date of therapy initiation through the date of a switch to another antiosteoporosis drug or formulation, date they left the plan, or Dec. 31, 2003—whichever came first. An adherence ratio was calculated by dividing the cumulative number of bisphosphonate therapy days by the number of elapsed calendar days (from therapy initiation). To calculate these measures, the researchers identified all outpatient pharmacy claims for weekly and daily bisphosphonate therapy based on corresponding codes from the National Drug Code system, arrayed them temporally based on dispensing dates, and assessed days of therapy supplied for each script based on the quantity of pills dispensed.

Within 6 months of initiating therapy, 57% of the 9,117 women on weekly therapy and 62% of the 3,421 women on daily therapy were considered to have adherence failure—defined as an adherence ratio less than 80%.

At 1 year, 66% of those on weekly therapy and 71% of those on daily therapy had adherence failure. At 2.5 years, the rates were 80% for weekly therapy and 82% for daily therapy.

After adjusting for age, fracture history, drug received, selected comorbid conditions, and selected concomitant medications, the two groups did not differ in risk of adherence failure. Risk of adherence failure was higher among women aged 65 years and older but was lower in those with a history of fracture.

The researchers did not assess adherence for specific drugs.

The research was funded by Amgen Inc., which is currently investigating a fully monoclonal antibody for the treatment of osteoporosis.

WASHINGTON — Even neurologists are missing the diagnosis of drug-induced parkinsonism, according to an informal study of patients at one movement disorder clinic presented at the World Parkinson Congress.

Overall 8% (23 of 304 patients) of all cases of new patients with parkinsonian symptoms seen at the Emory University movement disorders clinic between January 2004 and January 2006 were diagnosed with drug-induced parkinsonism (DIP), said Dr. Stewart A. Factor, director of the movement disorders program at Emory University.

The age at diagnosis ranged between 49 and 97 years; the age at onset ranged between 48 and 96 years. Patients were predominantly female (73%). Records were available for 22 patients with DIP.

“Seventeen of the 22 patients had been seen previously by neurologists, and yet only 2 of them were diagnosed with drug-induced parkinsonism,” said Dr. Factor. Of these, 10 were misdiagnosed with Parkinson's disease (PD) and were treated with antiparkinsonian drugs. Seven patients had no clear diagnosis.

DIP, defined by Dr. Factor to include tardive dyskinesia, is misdiagnosed frequently; it has been estimated variously that only 1 in 16 cases and 2 in 12 patients with DIP are correctly diagnosed. “What I'm seeing is that even neurologists are missing this diagnosis.”

The older, conventional antipsychotic drugs have been most commonly associated with DIP. It has been assumed that the risk of DIP was reduced with the introduction of atypical antipsychotic drugs. However, Dr. Factor's experience has been just the opposite. Only three patients in his clinic developed DIP in response to typical antipsychotics (haloperidol, trifluoperazine, and amoxapine). In contrast, 12 cases were caused by atypical antipsychotics (3 from risperidone, 6 from olanzapine, 1 from ziprasidone, and 2 from aripiprazole). Five cases were caused by metoclopramide and two were caused by drug combinations (metoclopramide/reserpine, metoclopramide/ziprasidone).

In terms of clinical features, 11 patients had tardive dyskinesia (including 5 with respiratory dyskinesia), 2 had akathisia, 19 had tremor (17 with resting tremor and 6 with asymmetric tremor, alone or in combination), and 3 had akinetic rigidity. Clinically, 11 patients had psychiatric diagnoses—primarily mood disorders (9 patients)—and 6 patients had neurologic diagnoses (dementia, Huntington's chorea, hydrocephalus). Of the 13 patients who stopped the drug and returned for follow-up, 12 showed an improvement in symptoms within about 6 months. DIP has a subacute onset and all of the cardinal features of Parkinson's disease—tremor, rigidity, bradykinesia, and abnormalities of posture, gait, and balance—can be seen. Akinetic rigidity (without tremor) is seen in more than half of patients with DIP. Drug-use history and tardive dyskinesia appear to be key to the differential diagnosis.

Several other factors can also help differentiate DIP from PD, including subacute onset, bilateral features, more postural tremor than resting tremor, and the presence of other extrapyramidal signs.

Among psychiatric patients, 90% of DIP cases have their onset in the first 3 months of drug use or within 3 months of a dosage increase. The condition may reverse spontaneously, though this is rare. The condition may also be chronic and progressive. Most importantly, withdrawal of the drug does not lead to immediate improvement of symptoms, typically taking up to 6 months to resolve.

Metoclopramide, an antiemetic drug used primarily for gastrointestinal disorders, has also been implicated in DIP. Though the drug is intended for short-term use (2–8 weeks), many patients are treated long term with this drug. “With chronic use, they develop drug-induced parkinsonism or tardive dyskinesia,” said Dr. Factor.

The prevalence of DIP among psychiatric patients on metoclopramide may be as great as 25%, according to estimates. Women tend to be affected more frequently than men, particularly older women. Among patients with metoclopramide-induced parkinsonism, up to 70% have tremor, 70% have postural instability, and 40% have tardive dyskinesia. Once the drug is stopped, improvement typically takes 4 months.

In addition to neuroleptics and metoclopramide, there have been reports of a number of other drugs associated with DIP. These include SSRIs, dopamine depleters, bupropion, phenelzine, lithium, valproate, some cardiac drugs (amiodarone, captopril, verapamil, diltiazem, amlodipine, manidipine, methyldopa), and estrogens.

There are a number of risk factors for developing DIP. In particular, women appear to be twice as likely as men to develop the disorder. Older age (older than age 65) is associated with a five times greater risk. Greater drug potency or dose also plays a role. Less frequently described potential risk factors include prior brain injury, dementia, HIV infection, certain psychiatric disorders (mood disorders in particular), the presence of tardive dyskinesia, and a family history of PD.

“Recognition is the key to proper management because if you recognize that the drug causes it, you stop the drug if you can and the symptoms will reverse in most patients.”

In addition, amantadine and anticholinergics are frequently used to treat symptoms. Other potential treatments include levodopa, electroconvulsive therapy, propranolol, and clozapine.

WASHINGTON — Even neurologists are missing the diagnosis of drug-induced parkinsonism, according to an informal study of patients at one movement disorder clinic presented at the World Parkinson Congress.

Overall 8% (23 of 304 patients) of all cases of new patients with parkinsonian symptoms seen at the Emory University movement disorders clinic between January 2004 and January 2006 were diagnosed with drug-induced parkinsonism (DIP), said Dr. Stewart A. Factor, director of the movement disorders program at Emory University.

The age at diagnosis ranged between 49 and 97 years; the age at onset ranged between 48 and 96 years. Patients were predominantly female (73%). Records were available for 22 patients with DIP.

“Seventeen of the 22 patients had been seen previously by neurologists, and yet only 2 of them were diagnosed with drug-induced parkinsonism,” said Dr. Factor. Of these, 10 were misdiagnosed with Parkinson's disease (PD) and were treated with antiparkinsonian drugs. Seven patients had no clear diagnosis.

DIP, defined by Dr. Factor to include tardive dyskinesia, is misdiagnosed frequently; it has been estimated variously that only 1 in 16 cases and 2 in 12 patients with DIP are correctly diagnosed. “What I'm seeing is that even neurologists are missing this diagnosis.”

The older, conventional antipsychotic drugs have been most commonly associated with DIP. It has been assumed that the risk of DIP was reduced with the introduction of atypical antipsychotic drugs. However, Dr. Factor's experience has been just the opposite. Only three patients in his clinic developed DIP in response to typical antipsychotics (haloperidol, trifluoperazine, and amoxapine). In contrast, 12 cases were caused by atypical antipsychotics (3 from risperidone, 6 from olanzapine, 1 from ziprasidone, and 2 from aripiprazole). Five cases were caused by metoclopramide and two were caused by drug combinations (metoclopramide/reserpine, metoclopramide/ziprasidone).

In terms of clinical features, 11 patients had tardive dyskinesia (including 5 with respiratory dyskinesia), 2 had akathisia, 19 had tremor (17 with resting tremor and 6 with asymmetric tremor, alone or in combination), and 3 had akinetic rigidity. Clinically, 11 patients had psychiatric diagnoses—primarily mood disorders (9 patients)—and 6 patients had neurologic diagnoses (dementia, Huntington's chorea, hydrocephalus). Of the 13 patients who stopped the drug and returned for follow-up, 12 showed an improvement in symptoms within about 6 months. DIP has a subacute onset and all of the cardinal features of Parkinson's disease—tremor, rigidity, bradykinesia, and abnormalities of posture, gait, and balance—can be seen. Akinetic rigidity (without tremor) is seen in more than half of patients with DIP. Drug-use history and tardive dyskinesia appear to be key to the differential diagnosis.

Several other factors can also help differentiate DIP from PD, including subacute onset, bilateral features, more postural tremor than resting tremor, and the presence of other extrapyramidal signs.

Among psychiatric patients, 90% of DIP cases have their onset in the first 3 months of drug use or within 3 months of a dosage increase. The condition may reverse spontaneously, though this is rare. The condition may also be chronic and progressive. Most importantly, withdrawal of the drug does not lead to immediate improvement of symptoms, typically taking up to 6 months to resolve.

Metoclopramide, an antiemetic drug used primarily for gastrointestinal disorders, has also been implicated in DIP. Though the drug is intended for short-term use (2–8 weeks), many patients are treated long term with this drug. “With chronic use, they develop drug-induced parkinsonism or tardive dyskinesia,” said Dr. Factor.

The prevalence of DIP among psychiatric patients on metoclopramide may be as great as 25%, according to estimates. Women tend to be affected more frequently than men, particularly older women. Among patients with metoclopramide-induced parkinsonism, up to 70% have tremor, 70% have postural instability, and 40% have tardive dyskinesia. Once the drug is stopped, improvement typically takes 4 months.

In addition to neuroleptics and metoclopramide, there have been reports of a number of other drugs associated with DIP. These include SSRIs, dopamine depleters, bupropion, phenelzine, lithium, valproate, some cardiac drugs (amiodarone, captopril, verapamil, diltiazem, amlodipine, manidipine, methyldopa), and estrogens.

There are a number of risk factors for developing DIP. In particular, women appear to be twice as likely as men to develop the disorder. Older age (older than age 65) is associated with a five times greater risk. Greater drug potency or dose also plays a role. Less frequently described potential risk factors include prior brain injury, dementia, HIV infection, certain psychiatric disorders (mood disorders in particular), the presence of tardive dyskinesia, and a family history of PD.

“Recognition is the key to proper management because if you recognize that the drug causes it, you stop the drug if you can and the symptoms will reverse in most patients.”

In addition, amantadine and anticholinergics are frequently used to treat symptoms. Other potential treatments include levodopa, electroconvulsive therapy, propranolol, and clozapine.

WASHINGTON — Even neurologists are missing the diagnosis of drug-induced parkinsonism, according to an informal study of patients at one movement disorder clinic presented at the World Parkinson Congress.

Overall 8% (23 of 304 patients) of all cases of new patients with parkinsonian symptoms seen at the Emory University movement disorders clinic between January 2004 and January 2006 were diagnosed with drug-induced parkinsonism (DIP), said Dr. Stewart A. Factor, director of the movement disorders program at Emory University.

The age at diagnosis ranged between 49 and 97 years; the age at onset ranged between 48 and 96 years. Patients were predominantly female (73%). Records were available for 22 patients with DIP.

“Seventeen of the 22 patients had been seen previously by neurologists, and yet only 2 of them were diagnosed with drug-induced parkinsonism,” said Dr. Factor. Of these, 10 were misdiagnosed with Parkinson's disease (PD) and were treated with antiparkinsonian drugs. Seven patients had no clear diagnosis.

DIP, defined by Dr. Factor to include tardive dyskinesia, is misdiagnosed frequently; it has been estimated variously that only 1 in 16 cases and 2 in 12 patients with DIP are correctly diagnosed. “What I'm seeing is that even neurologists are missing this diagnosis.”

The older, conventional antipsychotic drugs have been most commonly associated with DIP. It has been assumed that the risk of DIP was reduced with the introduction of atypical antipsychotic drugs. However, Dr. Factor's experience has been just the opposite. Only three patients in his clinic developed DIP in response to typical antipsychotics (haloperidol, trifluoperazine, and amoxapine). In contrast, 12 cases were caused by atypical antipsychotics (3 from risperidone, 6 from olanzapine, 1 from ziprasidone, and 2 from aripiprazole). Five cases were caused by metoclopramide and two were caused by drug combinations (metoclopramide/reserpine, metoclopramide/ziprasidone).

In terms of clinical features, 11 patients had tardive dyskinesia (including 5 with respiratory dyskinesia), 2 had akathisia, 19 had tremor (17 with resting tremor and 6 with asymmetric tremor, alone or in combination), and 3 had akinetic rigidity. Clinically, 11 patients had psychiatric diagnoses—primarily mood disorders (9 patients)—and 6 patients had neurologic diagnoses (dementia, Huntington's chorea, hydrocephalus). Of the 13 patients who stopped the drug and returned for follow-up, 12 showed an improvement in symptoms within about 6 months. DIP has a subacute onset and all of the cardinal features of Parkinson's disease—tremor, rigidity, bradykinesia, and abnormalities of posture, gait, and balance—can be seen. Akinetic rigidity (without tremor) is seen in more than half of patients with DIP. Drug-use history and tardive dyskinesia appear to be key to the differential diagnosis.

Several other factors can also help differentiate DIP from PD, including subacute onset, bilateral features, more postural tremor than resting tremor, and the presence of other extrapyramidal signs.

Among psychiatric patients, 90% of DIP cases have their onset in the first 3 months of drug use or within 3 months of a dosage increase. The condition may reverse spontaneously, though this is rare. The condition may also be chronic and progressive. Most importantly, withdrawal of the drug does not lead to immediate improvement of symptoms, typically taking up to 6 months to resolve.

Metoclopramide, an antiemetic drug used primarily for gastrointestinal disorders, has also been implicated in DIP. Though the drug is intended for short-term use (2–8 weeks), many patients are treated long term with this drug. “With chronic use, they develop drug-induced parkinsonism or tardive dyskinesia,” said Dr. Factor.

The prevalence of DIP among psychiatric patients on metoclopramide may be as great as 25%, according to estimates. Women tend to be affected more frequently than men, particularly older women. Among patients with metoclopramide-induced parkinsonism, up to 70% have tremor, 70% have postural instability, and 40% have tardive dyskinesia. Once the drug is stopped, improvement typically takes 4 months.

In addition to neuroleptics and metoclopramide, there have been reports of a number of other drugs associated with DIP. These include SSRIs, dopamine depleters, bupropion, phenelzine, lithium, valproate, some cardiac drugs (amiodarone, captopril, verapamil, diltiazem, amlodipine, manidipine, methyldopa), and estrogens.

There are a number of risk factors for developing DIP. In particular, women appear to be twice as likely as men to develop the disorder. Older age (older than age 65) is associated with a five times greater risk. Greater drug potency or dose also plays a role. Less frequently described potential risk factors include prior brain injury, dementia, HIV infection, certain psychiatric disorders (mood disorders in particular), the presence of tardive dyskinesia, and a family history of PD.

“Recognition is the key to proper management because if you recognize that the drug causes it, you stop the drug if you can and the symptoms will reverse in most patients.”

In addition, amantadine and anticholinergics are frequently used to treat symptoms. Other potential treatments include levodopa, electroconvulsive therapy, propranolol, and clozapine.