Kerri Wachter

WASHINGTON — Higher intake of n-3 fatty acids may protect against cognitive impairment, according to data presented at the annual meeting of the Gerontological Society of America.

In a study of almost 1,000 people aged 65 years and older, those with dementia had significantly lower plasma levels of n-3 fatty acids, said Antonio Cherubini, M.D., of the Institute of Gerontology and Geriatrics in Perugia, Italy.

The n-3 fatty acids are an important component of the neuronal membrane, influencing membrane fluidity and all the related functions, such as signal transduction and enzyme function. Fish—particularly fatty fish, such as mackerel and albacore tuna—are the primary source of n-3 fatty acids.

Dr. Cherubini presented data from the Aging in Chianti [Italy] (InCHIANTI) study, a population-based trial conducted between 1998 and 2000.

The 935 volunteers were categorized as having normal cognition (725 subjects), cognitive impairment without meeting the DSM-IV criteria for dementia (153 subjects), or dementia (57 subjects). Cognitive function was screened using the Mini-Mental State Examination. The subjects with age- and education-unadjusted scores lower than 26 on the examination underwent more detailed tests. Plasma fatty acid levels were determined using gas chromatography.

Subjects with dementia had the lowest n-3 fatty acid plasma concentrations—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 2.7%, compared with 3.0% for the cognitively impaired group and 3.2% for the normal cognition group.

Subjects with dementia had the highest plasma concentrations of saturated fatty acids—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 31.4%, compared with 30.1% for the cognitive impairment group and 30.3% for the normal cognition group.

“Subjects in the second group—those who have cognitive impairment but not dementia—tended to have intermediate values in many of the fatty acids,” Dr. Cherubini said.

The finding of lower n-3 fatty acid plasma concentrations persisted only in subjects with dementia after adjusting for age, gender, education, smoking status, cholesterol and triacylglycerol levels, alcohol, fatty acid and total energy daily intakes, and total plasma levels of fatty acids.

WASHINGTON — Higher intake of n-3 fatty acids may protect against cognitive impairment, according to data presented at the annual meeting of the Gerontological Society of America.

In a study of almost 1,000 people aged 65 years and older, those with dementia had significantly lower plasma levels of n-3 fatty acids, said Antonio Cherubini, M.D., of the Institute of Gerontology and Geriatrics in Perugia, Italy.

The n-3 fatty acids are an important component of the neuronal membrane, influencing membrane fluidity and all the related functions, such as signal transduction and enzyme function. Fish—particularly fatty fish, such as mackerel and albacore tuna—are the primary source of n-3 fatty acids.

Dr. Cherubini presented data from the Aging in Chianti [Italy] (InCHIANTI) study, a population-based trial conducted between 1998 and 2000.

The 935 volunteers were categorized as having normal cognition (725 subjects), cognitive impairment without meeting the DSM-IV criteria for dementia (153 subjects), or dementia (57 subjects). Cognitive function was screened using the Mini-Mental State Examination. The subjects with age- and education-unadjusted scores lower than 26 on the examination underwent more detailed tests. Plasma fatty acid levels were determined using gas chromatography.

Subjects with dementia had the lowest n-3 fatty acid plasma concentrations—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 2.7%, compared with 3.0% for the cognitively impaired group and 3.2% for the normal cognition group.

Subjects with dementia had the highest plasma concentrations of saturated fatty acids—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 31.4%, compared with 30.1% for the cognitive impairment group and 30.3% for the normal cognition group.

“Subjects in the second group—those who have cognitive impairment but not dementia—tended to have intermediate values in many of the fatty acids,” Dr. Cherubini said.

The finding of lower n-3 fatty acid plasma concentrations persisted only in subjects with dementia after adjusting for age, gender, education, smoking status, cholesterol and triacylglycerol levels, alcohol, fatty acid and total energy daily intakes, and total plasma levels of fatty acids.

WASHINGTON — Higher intake of n-3 fatty acids may protect against cognitive impairment, according to data presented at the annual meeting of the Gerontological Society of America.

In a study of almost 1,000 people aged 65 years and older, those with dementia had significantly lower plasma levels of n-3 fatty acids, said Antonio Cherubini, M.D., of the Institute of Gerontology and Geriatrics in Perugia, Italy.

The n-3 fatty acids are an important component of the neuronal membrane, influencing membrane fluidity and all the related functions, such as signal transduction and enzyme function. Fish—particularly fatty fish, such as mackerel and albacore tuna—are the primary source of n-3 fatty acids.

Dr. Cherubini presented data from the Aging in Chianti [Italy] (InCHIANTI) study, a population-based trial conducted between 1998 and 2000.

The 935 volunteers were categorized as having normal cognition (725 subjects), cognitive impairment without meeting the DSM-IV criteria for dementia (153 subjects), or dementia (57 subjects). Cognitive function was screened using the Mini-Mental State Examination. The subjects with age- and education-unadjusted scores lower than 26 on the examination underwent more detailed tests. Plasma fatty acid levels were determined using gas chromatography.

Subjects with dementia had the lowest n-3 fatty acid plasma concentrations—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 2.7%, compared with 3.0% for the cognitively impaired group and 3.2% for the normal cognition group.

Subjects with dementia had the highest plasma concentrations of saturated fatty acids—as a percentage of total fatty acid plasma concentrations in mg/L—with a mean of 31.4%, compared with 30.1% for the cognitive impairment group and 30.3% for the normal cognition group.

“Subjects in the second group—those who have cognitive impairment but not dementia—tended to have intermediate values in many of the fatty acids,” Dr. Cherubini said.

The finding of lower n-3 fatty acid plasma concentrations persisted only in subjects with dementia after adjusting for age, gender, education, smoking status, cholesterol and triacylglycerol levels, alcohol, fatty acid and total energy daily intakes, and total plasma levels of fatty acids.

WASHINGTON – Children with new-onset epileptic seizures appear to have more behavior problems than do those without the disorder, David W. Dunn, M.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“We know that kids with new-onset seizures have more problems at baseline than siblings. This suggests to us that there's got to be something going on already before” children have a first seizure, said Dr. Dunn of Indiana University in Indianapolis.

The researchers enrolled 356 children aged 6–14 years who had their first recognized seizure within the past 3 months.

Their siblings, also aged 6–14 years (205), were recruited as controls. The Child Behavior Checklist (CBCL) was used to measure behavior problems. The genders were roughly equal in the group of children with seizures, and the group was largely white (83%).

“We found that it was the children with prior unrecognized seizures who had the higher scores,” Dr. Dunn said. With the CBCL, a higher score provides greater evidence of behavior problems. Children with prior unrecognized seizures had a mean CBCL total score of 57, while those with true first seizures had a mean score of 54 and siblings had a mean score of 50.

About a third of the children who have prior unrecognized seizures already measured in the clinical range of the CBCL for behavior problems.

Just over 20% of the children with true first seizures measured in the clinical range, as did 16% of the siblings.

When the researchers looked at CBCL syndrome scores, they found “the highest mean syndrome scores were in attention problems,” he said.

In fact, 15% of children with prior unrecognized seizures and 9% of children with true first seizures were in the clinical range for attention problems.

Children with prior unrecognized seizures also had significantly higher rates of aggressive behavior and anxiety/depression, as well as higher withdrawal syndrome scores, than did children with true first seizures.

Dr. Dunn theorized that this might be a problem with children having some underlying central nervous system discharge that doesn't appear on an EEG.

“We are saying that there is probably some kind of underlying central nervous system dysfunction that causes both seizures and behavior problems,” he suggested.

These findings come from a baseline analysis that is part of a larger study, which will follow the children for several years.

“Our thought was that if behavior problems were due to recurrent seizures, medication effect, or the patient's reaction to illness, we wouldn't see very many behavior problems right at the very beginning of the epilepsy but these would build up over time.

“But if the behavior problems were due to some underlying central nervous system problem, then the behavior problems should be present at the beginning of the seizures and should persist,” Dr. Dunn said.

WASHINGTON – Children with new-onset epileptic seizures appear to have more behavior problems than do those without the disorder, David W. Dunn, M.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“We know that kids with new-onset seizures have more problems at baseline than siblings. This suggests to us that there's got to be something going on already before” children have a first seizure, said Dr. Dunn of Indiana University in Indianapolis.

The researchers enrolled 356 children aged 6–14 years who had their first recognized seizure within the past 3 months.

Their siblings, also aged 6–14 years (205), were recruited as controls. The Child Behavior Checklist (CBCL) was used to measure behavior problems. The genders were roughly equal in the group of children with seizures, and the group was largely white (83%).

“We found that it was the children with prior unrecognized seizures who had the higher scores,” Dr. Dunn said. With the CBCL, a higher score provides greater evidence of behavior problems. Children with prior unrecognized seizures had a mean CBCL total score of 57, while those with true first seizures had a mean score of 54 and siblings had a mean score of 50.

About a third of the children who have prior unrecognized seizures already measured in the clinical range of the CBCL for behavior problems.

Just over 20% of the children with true first seizures measured in the clinical range, as did 16% of the siblings.

When the researchers looked at CBCL syndrome scores, they found “the highest mean syndrome scores were in attention problems,” he said.

In fact, 15% of children with prior unrecognized seizures and 9% of children with true first seizures were in the clinical range for attention problems.

Children with prior unrecognized seizures also had significantly higher rates of aggressive behavior and anxiety/depression, as well as higher withdrawal syndrome scores, than did children with true first seizures.

Dr. Dunn theorized that this might be a problem with children having some underlying central nervous system discharge that doesn't appear on an EEG.

“We are saying that there is probably some kind of underlying central nervous system dysfunction that causes both seizures and behavior problems,” he suggested.

These findings come from a baseline analysis that is part of a larger study, which will follow the children for several years.

“Our thought was that if behavior problems were due to recurrent seizures, medication effect, or the patient's reaction to illness, we wouldn't see very many behavior problems right at the very beginning of the epilepsy but these would build up over time.

“But if the behavior problems were due to some underlying central nervous system problem, then the behavior problems should be present at the beginning of the seizures and should persist,” Dr. Dunn said.

WASHINGTON – Children with new-onset epileptic seizures appear to have more behavior problems than do those without the disorder, David W. Dunn, M.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“We know that kids with new-onset seizures have more problems at baseline than siblings. This suggests to us that there's got to be something going on already before” children have a first seizure, said Dr. Dunn of Indiana University in Indianapolis.

The researchers enrolled 356 children aged 6–14 years who had their first recognized seizure within the past 3 months.

Their siblings, also aged 6–14 years (205), were recruited as controls. The Child Behavior Checklist (CBCL) was used to measure behavior problems. The genders were roughly equal in the group of children with seizures, and the group was largely white (83%).

“We found that it was the children with prior unrecognized seizures who had the higher scores,” Dr. Dunn said. With the CBCL, a higher score provides greater evidence of behavior problems. Children with prior unrecognized seizures had a mean CBCL total score of 57, while those with true first seizures had a mean score of 54 and siblings had a mean score of 50.

About a third of the children who have prior unrecognized seizures already measured in the clinical range of the CBCL for behavior problems.

Just over 20% of the children with true first seizures measured in the clinical range, as did 16% of the siblings.

When the researchers looked at CBCL syndrome scores, they found “the highest mean syndrome scores were in attention problems,” he said.

In fact, 15% of children with prior unrecognized seizures and 9% of children with true first seizures were in the clinical range for attention problems.

Children with prior unrecognized seizures also had significantly higher rates of aggressive behavior and anxiety/depression, as well as higher withdrawal syndrome scores, than did children with true first seizures.

Dr. Dunn theorized that this might be a problem with children having some underlying central nervous system discharge that doesn't appear on an EEG.

“We are saying that there is probably some kind of underlying central nervous system dysfunction that causes both seizures and behavior problems,” he suggested.

These findings come from a baseline analysis that is part of a larger study, which will follow the children for several years.

“Our thought was that if behavior problems were due to recurrent seizures, medication effect, or the patient's reaction to illness, we wouldn't see very many behavior problems right at the very beginning of the epilepsy but these would build up over time.

“But if the behavior problems were due to some underlying central nervous system problem, then the behavior problems should be present at the beginning of the seizures and should persist,” Dr. Dunn said.

WASHINGTON – Inner-city children with persistent asthma appear to have more problems with negative social skills, anxiety, and shyness than children without asthma, according to data presented at the annual meeting of the Pediatric Academic Societies.

“Children with persistent asthma symptoms had significantly more behavior problems across several domains, compared to children with no asthma symptoms,” said Jill S. Halterman, M.D., of the University of Rochester in New York.

Dr. Halterman and her colleagues looked at the relationship between asthma and behavior in all kindergarten children in the city of Rochester school district in 2003. At the beginning of that school year, parents of kindergarten children completed a detailed health and development survey assessing the child's background, behavioral functioning, and medical history–with specific questions about asthma symptoms.

Children were included if they were older than 4 years but younger than 6 years at the time of the survey, making a total of 1,619. Black children accounted for 60% of the survey population; Hispanic children accounted for 22%. A majority of the children (59%) received Medicaid insurance.

Asthma status–no asthma, intermittent asthma, or persistent asthma–was determined from parent responses to three questions about asthma symptoms. The criteria for these three categories were based on the National Heart, Lung, and Blood Institute's guidelines for defining asthma severity. Seven percent of the children had intermittent asthma, and 8% had persistent asthma.

Using 12 items on the survey, a child's behavioral functioning was assessed using a 1–4 scale in four areas–positive and negative peer social skills, task orientation, and shyness/anxiety.

There was no difference between the three asthma groups for average positive peer social skills scores, but children with persistent asthma had worse scores for negative peer social skills than children with intermittent asthma or no asthma. Children with persistent asthma also had worse scores than the other two groups for task orientation skills and had higher scores for shyness/anxiety.

More than 20% of children in the persistent asthma group had worse scores (one standard deviation or greater) on two or more behavior measures, compared with 16% of those with intermittent asthma and 10% of those with no symptoms. Children with persistent symptoms were two times more likely than those without symptoms to score more than one standard deviation worse on two or more of the scales.

Multivariate regression analysis was used to evaluate the independent relationships between asthma status and the behaviors. There was no significant association among children with intermittent asthma and negative behaviors.

“For children with persistent asthma, a significant association was shown for negative peer and shy/anxious scores,” said Dr. Halterman, speaking at the meeting also sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON – Inner-city children with persistent asthma appear to have more problems with negative social skills, anxiety, and shyness than children without asthma, according to data presented at the annual meeting of the Pediatric Academic Societies.

“Children with persistent asthma symptoms had significantly more behavior problems across several domains, compared to children with no asthma symptoms,” said Jill S. Halterman, M.D., of the University of Rochester in New York.

Dr. Halterman and her colleagues looked at the relationship between asthma and behavior in all kindergarten children in the city of Rochester school district in 2003. At the beginning of that school year, parents of kindergarten children completed a detailed health and development survey assessing the child's background, behavioral functioning, and medical history–with specific questions about asthma symptoms.

Children were included if they were older than 4 years but younger than 6 years at the time of the survey, making a total of 1,619. Black children accounted for 60% of the survey population; Hispanic children accounted for 22%. A majority of the children (59%) received Medicaid insurance.

Asthma status–no asthma, intermittent asthma, or persistent asthma–was determined from parent responses to three questions about asthma symptoms. The criteria for these three categories were based on the National Heart, Lung, and Blood Institute's guidelines for defining asthma severity. Seven percent of the children had intermittent asthma, and 8% had persistent asthma.

Using 12 items on the survey, a child's behavioral functioning was assessed using a 1–4 scale in four areas–positive and negative peer social skills, task orientation, and shyness/anxiety.

There was no difference between the three asthma groups for average positive peer social skills scores, but children with persistent asthma had worse scores for negative peer social skills than children with intermittent asthma or no asthma. Children with persistent asthma also had worse scores than the other two groups for task orientation skills and had higher scores for shyness/anxiety.

More than 20% of children in the persistent asthma group had worse scores (one standard deviation or greater) on two or more behavior measures, compared with 16% of those with intermittent asthma and 10% of those with no symptoms. Children with persistent symptoms were two times more likely than those without symptoms to score more than one standard deviation worse on two or more of the scales.

Multivariate regression analysis was used to evaluate the independent relationships between asthma status and the behaviors. There was no significant association among children with intermittent asthma and negative behaviors.

“For children with persistent asthma, a significant association was shown for negative peer and shy/anxious scores,” said Dr. Halterman, speaking at the meeting also sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON – Inner-city children with persistent asthma appear to have more problems with negative social skills, anxiety, and shyness than children without asthma, according to data presented at the annual meeting of the Pediatric Academic Societies.

“Children with persistent asthma symptoms had significantly more behavior problems across several domains, compared to children with no asthma symptoms,” said Jill S. Halterman, M.D., of the University of Rochester in New York.

Dr. Halterman and her colleagues looked at the relationship between asthma and behavior in all kindergarten children in the city of Rochester school district in 2003. At the beginning of that school year, parents of kindergarten children completed a detailed health and development survey assessing the child's background, behavioral functioning, and medical history–with specific questions about asthma symptoms.

Children were included if they were older than 4 years but younger than 6 years at the time of the survey, making a total of 1,619. Black children accounted for 60% of the survey population; Hispanic children accounted for 22%. A majority of the children (59%) received Medicaid insurance.

Asthma status–no asthma, intermittent asthma, or persistent asthma–was determined from parent responses to three questions about asthma symptoms. The criteria for these three categories were based on the National Heart, Lung, and Blood Institute's guidelines for defining asthma severity. Seven percent of the children had intermittent asthma, and 8% had persistent asthma.

Using 12 items on the survey, a child's behavioral functioning was assessed using a 1–4 scale in four areas–positive and negative peer social skills, task orientation, and shyness/anxiety.

There was no difference between the three asthma groups for average positive peer social skills scores, but children with persistent asthma had worse scores for negative peer social skills than children with intermittent asthma or no asthma. Children with persistent asthma also had worse scores than the other two groups for task orientation skills and had higher scores for shyness/anxiety.

More than 20% of children in the persistent asthma group had worse scores (one standard deviation or greater) on two or more behavior measures, compared with 16% of those with intermittent asthma and 10% of those with no symptoms. Children with persistent symptoms were two times more likely than those without symptoms to score more than one standard deviation worse on two or more of the scales.

Multivariate regression analysis was used to evaluate the independent relationships between asthma status and the behaviors. There was no significant association among children with intermittent asthma and negative behaviors.

“For children with persistent asthma, a significant association was shown for negative peer and shy/anxious scores,” said Dr. Halterman, speaking at the meeting also sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

The ASSENT-4 trial, designed to test a single-bolus thrombolytic in combination with percutaneous coronary intervention for acute myocardial infarction, was suspended in April with fewer than half of the planned 4,000 patients enrolled.

The Data Safety and Monitoring Board's decision to put the Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction (ASSENT-4) trial on hold “was based on an unexpectedly superior outcome in patients randomized to the direct [percutaneous coronary intervention] only arm,” according to a statement by the trial's executive committee.

To date 1,635 patients have been randomized to receive either a single bolus of Metalyse/ TNKase (tenecteplase) plus unfractionated heparin followed by immediate percutaneous coronary intervention (PCI) or PCI alone. The committee noted that “the rates of death and of [intracerebral hemorrhage] in the TNK-facilitated PCI arm are consistent with prior ASSENT fibrinolytic alone studies.”

The committee is currently collecting and assessing study data in order to determine the future of the investigation.

“This study shows that there is in fact a prothrombotic effect of thrombolysis. Thus, it is important to choose a particular strategy—either primary PCI or thrombolysis, but not … both,” Christopher Cannon, M.D., of Brigham and Women's Hospital in Boston, and a principal investigator with the Thrombolysis in Myocardial Infarction (TIMI) study group, told this newspaper.

The ASSENT-4 trial, designed to test a single-bolus thrombolytic in combination with percutaneous coronary intervention for acute myocardial infarction, was suspended in April with fewer than half of the planned 4,000 patients enrolled.

The Data Safety and Monitoring Board's decision to put the Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction (ASSENT-4) trial on hold “was based on an unexpectedly superior outcome in patients randomized to the direct [percutaneous coronary intervention] only arm,” according to a statement by the trial's executive committee.

To date 1,635 patients have been randomized to receive either a single bolus of Metalyse/ TNKase (tenecteplase) plus unfractionated heparin followed by immediate percutaneous coronary intervention (PCI) or PCI alone. The committee noted that “the rates of death and of [intracerebral hemorrhage] in the TNK-facilitated PCI arm are consistent with prior ASSENT fibrinolytic alone studies.”

The committee is currently collecting and assessing study data in order to determine the future of the investigation.

“This study shows that there is in fact a prothrombotic effect of thrombolysis. Thus, it is important to choose a particular strategy—either primary PCI or thrombolysis, but not … both,” Christopher Cannon, M.D., of Brigham and Women's Hospital in Boston, and a principal investigator with the Thrombolysis in Myocardial Infarction (TIMI) study group, told this newspaper.

The ASSENT-4 trial, designed to test a single-bolus thrombolytic in combination with percutaneous coronary intervention for acute myocardial infarction, was suspended in April with fewer than half of the planned 4,000 patients enrolled.

The Data Safety and Monitoring Board's decision to put the Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction (ASSENT-4) trial on hold “was based on an unexpectedly superior outcome in patients randomized to the direct [percutaneous coronary intervention] only arm,” according to a statement by the trial's executive committee.

To date 1,635 patients have been randomized to receive either a single bolus of Metalyse/ TNKase (tenecteplase) plus unfractionated heparin followed by immediate percutaneous coronary intervention (PCI) or PCI alone. The committee noted that “the rates of death and of [intracerebral hemorrhage] in the TNK-facilitated PCI arm are consistent with prior ASSENT fibrinolytic alone studies.”

The committee is currently collecting and assessing study data in order to determine the future of the investigation.

“This study shows that there is in fact a prothrombotic effect of thrombolysis. Thus, it is important to choose a particular strategy—either primary PCI or thrombolysis, but not … both,” Christopher Cannon, M.D., of Brigham and Women's Hospital in Boston, and a principal investigator with the Thrombolysis in Myocardial Infarction (TIMI) study group, told this newspaper.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

LAKE BUENA VISTA, FLA. — The adjunctive use of aminolevulinic acid with intense pulsed light treatment appears to be more effective than the light therapy alone for the treatment of photoaging, said Ashish Bhatia, M.D., at the annual meeting of the American Society for Laser Medicine and Surgery.

Aminolevulinic acid (ALA) 20% topical solution is currently approved for the treatment of actinic keratoses of the face and scalp. "Many studies have suggested that the adjunctive use of ALA with intense pulsed light [IPL] can enhance the therapeutic effects of IPL used for photoaging," said Dr. Bhatia, a dermatologist in Naperville, Ill.

In a prospective study, 20 patients received treatment with ALA and IPL on one side of the face and IPL alone on the other. The trial was conducted at the facilities of SkinCare Physicians of Chestnut Hill in Boston.

Materials, equipment, and funding for the study were provided by DUSA Pharmaceuticals Inc., maker of Levulan Kerastick (ALA).

Patients underwent five treatments 3 weeks apart. The first three treatments were split face. For the ALA treatment, patients first underwent a vigorous acetone scrub. Once the ALA was applied, it remained in contact with the face for 30–60 minutes before being washed off. Both sides of the face were then treated with IPL. The final two treatments consisted of IPL alone.

A blinded investigator evaluated patients for five photodamage parameters—global photodamage, fine lines, mottled pigmentation, tactile roughness, and sallowness—prior to every treatment and 1 month of follow-up. Each parameter was rated on a 0–4 scale. Each patient also rated satisfaction for each side of the face at the end of the study. A blinded investigator was also asked to perform cosmetic evaluations at the end of the study.

Pretreatment with ALA resulted in significant improvement in global photodamage scores and in mottled pigmentation. Treatment with ALA resulted in significantly greater reductions of mottled pigmentation and fine lines (to low or imperceptible levels) than IPL alone.

Patient satisfaction was greater for the ALA combination treatment than it was for IPL alone. Likewise, the blinded investigator cosmetic evaluation was greater for the combination treatment than for IPL alone.

Both treatments were well tolerated, with very little difference between the two in terms of adverse effects, Dr. Bhatia said.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

ORLANDO, FLA. — Topical application of a special agent to improve the optical properties of darker skin types appears to significantly improve the efficacy of laser-assisted hair removal with fewer epidermal side effects, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

By using an optical clearing agent to improve laser light penetration at the skin surface, "we believe that in darker skin types … types I-V … we can definitely improve laser hair removal," said Misbah Khan, M.D., a laser surgery fellow at the Beckman Laser Institute at the University of California, Irvine.

The optical clearing agent—a polypropylene and polyethylene glycol mixture—decreases dermal scattering of light, thereby increasing laser light penetration. Once the optical clearing agent is applied to the skin, it is easier to see the dermal portion of the hair shaft, which led the researchers to suspect that it might also be easier to treat the hair.

In the study, the optical clearing agent was applied to one of each of 13 volunteers' underarms at least 2 hours prior to a single treatment with an alexandrite laser (GentleLase by Candela Corp.) in combination with cryogen spray cooling. The other side was treated with laser alone. Laser treatment was performed at various fluences depending on the volunteer's skin type, but both underarms of a single patient received the same fluence.

Hair counts in each area were performed before and 2 months after the procedure. Representative hairs also were clipped at the widest point of the base before and 2 months after treatment to determine hair diameter. In addition, the researchers assessed the areas for hyperpigmentation, hypopigmentation, and scarring.

"We were able to achieve more than a 70% reduction [in hair count] in a single treatment with the help of the optical clearing agent," said Dr. Khan. However, there was no significant difference in diameter between areas receiving the optical clearing agent and those receiving laser treatment alone.

In addition, with the use of the optical clearing agent, "we were able to substantially increase the depth and the extent of the thermal damage, and the immediate side effects of the laser-assisted hair removal were minimized to the degree that we didn't really see any," Dr. Khan said. A few volunteers required topical steroids for a day or 2 after the procedure on the side that did not receive the optical clearing agent.

Biopsies also were collected for histologic analysis. Cell viability stains were performed to assess the amount of thermal damage to the hair follicle. Hair follicles in areas treated with the optical clearing agent had much more evidence of thermal damage than did those in areas treated with laser alone.

The results are promising because even though several hair removal options are available for those who are considered to be good candidates, "there are limited treatment options available for people who are not good candidates, for example people with darker skin types and who also have dark hair," Dr. Khan said.

Longer wavelengths of laser light are one option because these do penetrate deeper. They are not well absorbed, though. Using shorter wavelengths instead typically leads to epidermal burns. The researchers believe that the optical clearing agent improves laser hair removal in patients with darker skin by allowing the use of shorter wavelengths while still avoiding dermal injury.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

LAKE BUENA VISTA, FLA. — Plasma skin resurfacing reduces acne scars and fine lines while minimizing downtime and adverse events, according to data presented at the annual meeting of the American Society for Laser Medicine and Surgery.

"Plasma skin regeneration provides an effective long-term facial rejuvenation for acne scarring and fine lines," said M. Potter, M.D., of RAFT Institute of Plastic Surgery in London.

The plasma device works by passing ultrahigh energy through nitrogen gas, generating plasma used to treat scars and lines with short pulses.

In this study, Dr. Potter treated a total of 11 patients (10 women)—3 for acne scars, 7 for fine lines, and 1 patient for both. The treatment was performed under anesthesia. Energy varied between 1 and 4 J.

All patients were assessed at 10 days and 3 and 6 months post treatment. "A precise measure of skin irregularity was recorded using silicon molds. … Wrinkle depth was assessed using a light microscope technique to give an accurate measurement," Dr. Potter said.

In patients with fine lines, the mean pretreatment wrinkle depth was 0.25 mm. At 10 days, there was a mean improvement in wrinkle depth of 39%. At 6 months, mean improvement was 24%. "Acne is always difficult to treat, but these patients had an improvement of 35% at 10 days and 23% at 6 months," Dr. Potter said.

WASHINGTON — Kidney disease can lead to complications during pregnancy—and pregnancy can worsen kidney disease, Phyllis August, M.D., said at a meeting sponsored by the National Kidney Foundation.

“Without normal renal function, pregnancy is threatened and not always successful, and pregnancy does pose a burden in women with compromised renal function,” said Dr. August, professor of medicine at the Cornell University cardiovascular center in New York.

During pregnancy, women undergo kidney and hemodynamic changes that can lead to or worsen chronic kidney disease (CKD). “The bottom line in patients with CKD or chronic renal insufficiency is that the outcome seems to be related to baseline blood pressure and the degree of renal insufficiency at the time of conception,” she said. In general, serum creatinine levels lower than 1.5 mg/dL and the absence of hypertension favor normal outcomes.

The approach to management depends on whether the patient is diagnosed with renal disease before conception or during pregnancy, or whether the disease onset occurs during pregnancy.

Encourage patients with severe CKD to wait until they have had a transplant before becoming pregnant. “Dialysis and pregnancy are not a good combination,” Dr. August said.

Pregnancy has temporary effects on renal disease. Urinary protein excretion is increased, with normal excretion ranging up to 300 mg/day during pregnancy. “Many of our patients with chronic renal disease, particularly diabetic nephropathy, can have a significant increase in urinary protein excretion,” she said. It's unknown whether this increase has any adverse effects on the underlying kidney disease.

“There is the possibility that because of all of these phenomena that pregnancy could pose a burden on the kidney in women with preexisting renal disease, leading to permanent loss of function,” Dr. August said. But there are few data on the long-term effect of pregnancy on renal function in women with CKD.

Renal disease diagnosed before conception is typically diabetic nephropathy or chronic glomerular nephritis. Previous studies suggested that earlier deliveries and smaller babies were the rule in this population. More recent data suggest that the worse the renal disease is prior to pregnancy, the worse the outcome of the pregnancy will be. Some data suggest that pregnancy does not lead to progression of diabetic nephropathy.

Management of diabetic nephropathy during pregnancy should rely on tight control of blood sugar, especially during the first trimester. There is a clear association between abnormal glucose control and fetal malformations. Also discontinue the use of ACE inhibitors and angiotensin II receptor blockers. Instead, antihypertensive therapy should be accomplished with methyldopa, labetalol, calcium antagonists, and occasional use of diuretics, Dr. August advised.

Women with a long history of type 1 diabetes should have a thorough cardiac evaluation with a stress test and an echocardiogram prior to pregnancy. Once pregnant, these patients should have a laboratory evaluation about every month, she recommended.

Many women with CKD have a risk of developing superimposed preeclampsia. The higher a woman's creatinine level is, the greater the risk. Pregnant women with preexisting CKD and preeclampsia have a higher incidence of premature delivery and restricted fetus growth than do women without CKD. “Most women with renal disease will have premature deliveries, and many will have smaller babies,” Dr. August said.

In some cases, renal disease becomes clinically apparent for the first time during pregnancy. Increased renal hemodynamics during pregnancy can unmask proteinuria. Close monitoring of blood pressure and urine during pregnancy may bring problems to light.

Renal evaluation of patients first suspected of having CKD during pregnancy is similar to that for patients who are not pregnant—serologic and function testing, and ultrasound.

A biopsy can even be performed, but it is common to avoid this measure during the third trimester of pregnancy because of anatomical and positioning issues.

Generally, only deteriorating kidney function or morbid nephritic syndrome is considered to be an indication for attempting a biopsy during pregnancy. Otherwise, it is preferred to wait until after delivery, Dr. August said.

It can be difficult to distinguish between intrinsic renal disease and preeclampsia. Renal disease can occur at any gestational age, but preeclampsia occurs after 20 weeks. Serum creatinine levels between 0.8 and 1.2 mg/dl are associated with preeclampsia, while levels of 1.5–1.8 mg/dL and higher are associated with renal disease.

“You almost never see azotemia in the setting of preeclampsia without proteinuria,” she said. In addition, intrinsic renal disease can occur with normal blood pressure, but a patient must be hypertensive to have preeclampsia.

Managing chronic renal disease during pregnancy requires a team approach that includes nephrologists. Dr. August recommends that patients be monitored frequently for preeclampsia—and for renal protection—blood pressure should be maintained within a slightly lower range than normal.

How Pregnancy Affects Kidney Function

Normal pregnancies have complex effects on the kidneys and on hemodynamics—changes that bear keeping in mind when evaluating pregnant patients with chronic kidney disease, Dr. August said.

During pregnancy, kidney size, blood flow, and glomerular filtration rate (GFR) all increase. GFR increases by as much as 50%, said Dr. August, of Cornell University in New York.

Renal vasodilation leads to increases in renin, urinary protein, aldosterone excretion, sodium and water reabsorption, glycosuria, and aminoaciduria. There are concomitant decreases in uric acid reabsorption and serum creatinine, sodium, and osmolarity. Normal serum sodium for a pregnant woman is in the 135–137 mmol/L range. Likewise, serum creatinine levels can be as low as 0.5 mg/dL and is usually 0.6 mg/dL; levels above 0.8 mg/dL indicate a decreased GFR, she said.

Uric acid levels also are lower in pregnant women—something to keep in mind when evaluating patients for possible preeclampsia, which causes serum uric acid levels to rise. In the second trimester, the normal uric acid level is usually not much higher than 3.5 mg/dL, and in the third trimester, it can go up as high as 4.5 mg/dL. “Anything higher than that is not quite normal,” Dr. August said.

Dilation of the urinary tract in pregnancy increases susceptibility to urinary tract infections. She recommends monthly screening for asymptomatic bacteriuria in pregnant women who are prone to urinary tract infections. Acute pyelonephritis can be much more serious than usual in pregnant women.

Hemodynamic changes during pregnancy include decreased blood pressure and increased cardiac output, heart rate, and respiratory rate. Some of these changes can actually be helpful for women with chronic kidney disease. Women who have been treated for hypertension and/or chronic kidney disease before pregnancy may require fewer medications during pregnancy.

WASHINGTON — Kidney disease can lead to complications during pregnancy—and pregnancy can worsen kidney disease, Phyllis August, M.D., said at a meeting sponsored by the National Kidney Foundation.

“Without normal renal function, pregnancy is threatened and not always successful, and pregnancy does pose a burden in women with compromised renal function,” said Dr. August, professor of medicine at the Cornell University cardiovascular center in New York.

During pregnancy, women undergo kidney and hemodynamic changes that can lead to or worsen chronic kidney disease (CKD). “The bottom line in patients with CKD or chronic renal insufficiency is that the outcome seems to be related to baseline blood pressure and the degree of renal insufficiency at the time of conception,” she said. In general, serum creatinine levels lower than 1.5 mg/dL and the absence of hypertension favor normal outcomes.

The approach to management depends on whether the patient is diagnosed with renal disease before conception or during pregnancy, or whether the disease onset occurs during pregnancy.

Encourage patients with severe CKD to wait until they have had a transplant before becoming pregnant. “Dialysis and pregnancy are not a good combination,” Dr. August said.

Pregnancy has temporary effects on renal disease. Urinary protein excretion is increased, with normal excretion ranging up to 300 mg/day during pregnancy. “Many of our patients with chronic renal disease, particularly diabetic nephropathy, can have a significant increase in urinary protein excretion,” she said. It's unknown whether this increase has any adverse effects on the underlying kidney disease.

“There is the possibility that because of all of these phenomena that pregnancy could pose a burden on the kidney in women with preexisting renal disease, leading to permanent loss of function,” Dr. August said. But there are few data on the long-term effect of pregnancy on renal function in women with CKD.

Renal disease diagnosed before conception is typically diabetic nephropathy or chronic glomerular nephritis. Previous studies suggested that earlier deliveries and smaller babies were the rule in this population. More recent data suggest that the worse the renal disease is prior to pregnancy, the worse the outcome of the pregnancy will be. Some data suggest that pregnancy does not lead to progression of diabetic nephropathy.

Management of diabetic nephropathy during pregnancy should rely on tight control of blood sugar, especially during the first trimester. There is a clear association between abnormal glucose control and fetal malformations. Also discontinue the use of ACE inhibitors and angiotensin II receptor blockers. Instead, antihypertensive therapy should be accomplished with methyldopa, labetalol, calcium antagonists, and occasional use of diuretics, Dr. August advised.

Women with a long history of type 1 diabetes should have a thorough cardiac evaluation with a stress test and an echocardiogram prior to pregnancy. Once pregnant, these patients should have a laboratory evaluation about every month, she recommended.

Many women with CKD have a risk of developing superimposed preeclampsia. The higher a woman's creatinine level is, the greater the risk. Pregnant women with preexisting CKD and preeclampsia have a higher incidence of premature delivery and restricted fetus growth than do women without CKD. “Most women with renal disease will have premature deliveries, and many will have smaller babies,” Dr. August said.

In some cases, renal disease becomes clinically apparent for the first time during pregnancy. Increased renal hemodynamics during pregnancy can unmask proteinuria. Close monitoring of blood pressure and urine during pregnancy may bring problems to light.

Renal evaluation of patients first suspected of having CKD during pregnancy is similar to that for patients who are not pregnant—serologic and function testing, and ultrasound.

A biopsy can even be performed, but it is common to avoid this measure during the third trimester of pregnancy because of anatomical and positioning issues.

Generally, only deteriorating kidney function or morbid nephritic syndrome is considered to be an indication for attempting a biopsy during pregnancy. Otherwise, it is preferred to wait until after delivery, Dr. August said.

It can be difficult to distinguish between intrinsic renal disease and preeclampsia. Renal disease can occur at any gestational age, but preeclampsia occurs after 20 weeks. Serum creatinine levels between 0.8 and 1.2 mg/dl are associated with preeclampsia, while levels of 1.5–1.8 mg/dL and higher are associated with renal disease.

“You almost never see azotemia in the setting of preeclampsia without proteinuria,” she said. In addition, intrinsic renal disease can occur with normal blood pressure, but a patient must be hypertensive to have preeclampsia.

Managing chronic renal disease during pregnancy requires a team approach that includes nephrologists. Dr. August recommends that patients be monitored frequently for preeclampsia—and for renal protection—blood pressure should be maintained within a slightly lower range than normal.

How Pregnancy Affects Kidney Function

Normal pregnancies have complex effects on the kidneys and on hemodynamics—changes that bear keeping in mind when evaluating pregnant patients with chronic kidney disease, Dr. August said.

During pregnancy, kidney size, blood flow, and glomerular filtration rate (GFR) all increase. GFR increases by as much as 50%, said Dr. August, of Cornell University in New York.

Renal vasodilation leads to increases in renin, urinary protein, aldosterone excretion, sodium and water reabsorption, glycosuria, and aminoaciduria. There are concomitant decreases in uric acid reabsorption and serum creatinine, sodium, and osmolarity. Normal serum sodium for a pregnant woman is in the 135–137 mmol/L range. Likewise, serum creatinine levels can be as low as 0.5 mg/dL and is usually 0.6 mg/dL; levels above 0.8 mg/dL indicate a decreased GFR, she said.

Uric acid levels also are lower in pregnant women—something to keep in mind when evaluating patients for possible preeclampsia, which causes serum uric acid levels to rise. In the second trimester, the normal uric acid level is usually not much higher than 3.5 mg/dL, and in the third trimester, it can go up as high as 4.5 mg/dL. “Anything higher than that is not quite normal,” Dr. August said.

Dilation of the urinary tract in pregnancy increases susceptibility to urinary tract infections. She recommends monthly screening for asymptomatic bacteriuria in pregnant women who are prone to urinary tract infections. Acute pyelonephritis can be much more serious than usual in pregnant women.

Hemodynamic changes during pregnancy include decreased blood pressure and increased cardiac output, heart rate, and respiratory rate. Some of these changes can actually be helpful for women with chronic kidney disease. Women who have been treated for hypertension and/or chronic kidney disease before pregnancy may require fewer medications during pregnancy.

WASHINGTON — Kidney disease can lead to complications during pregnancy—and pregnancy can worsen kidney disease, Phyllis August, M.D., said at a meeting sponsored by the National Kidney Foundation.

“Without normal renal function, pregnancy is threatened and not always successful, and pregnancy does pose a burden in women with compromised renal function,” said Dr. August, professor of medicine at the Cornell University cardiovascular center in New York.

During pregnancy, women undergo kidney and hemodynamic changes that can lead to or worsen chronic kidney disease (CKD). “The bottom line in patients with CKD or chronic renal insufficiency is that the outcome seems to be related to baseline blood pressure and the degree of renal insufficiency at the time of conception,” she said. In general, serum creatinine levels lower than 1.5 mg/dL and the absence of hypertension favor normal outcomes.

The approach to management depends on whether the patient is diagnosed with renal disease before conception or during pregnancy, or whether the disease onset occurs during pregnancy.

Encourage patients with severe CKD to wait until they have had a transplant before becoming pregnant. “Dialysis and pregnancy are not a good combination,” Dr. August said.

Pregnancy has temporary effects on renal disease. Urinary protein excretion is increased, with normal excretion ranging up to 300 mg/day during pregnancy. “Many of our patients with chronic renal disease, particularly diabetic nephropathy, can have a significant increase in urinary protein excretion,” she said. It's unknown whether this increase has any adverse effects on the underlying kidney disease.

“There is the possibility that because of all of these phenomena that pregnancy could pose a burden on the kidney in women with preexisting renal disease, leading to permanent loss of function,” Dr. August said. But there are few data on the long-term effect of pregnancy on renal function in women with CKD.

Renal disease diagnosed before conception is typically diabetic nephropathy or chronic glomerular nephritis. Previous studies suggested that earlier deliveries and smaller babies were the rule in this population. More recent data suggest that the worse the renal disease is prior to pregnancy, the worse the outcome of the pregnancy will be. Some data suggest that pregnancy does not lead to progression of diabetic nephropathy.

Management of diabetic nephropathy during pregnancy should rely on tight control of blood sugar, especially during the first trimester. There is a clear association between abnormal glucose control and fetal malformations. Also discontinue the use of ACE inhibitors and angiotensin II receptor blockers. Instead, antihypertensive therapy should be accomplished with methyldopa, labetalol, calcium antagonists, and occasional use of diuretics, Dr. August advised.

Women with a long history of type 1 diabetes should have a thorough cardiac evaluation with a stress test and an echocardiogram prior to pregnancy. Once pregnant, these patients should have a laboratory evaluation about every month, she recommended.

Many women with CKD have a risk of developing superimposed preeclampsia. The higher a woman's creatinine level is, the greater the risk. Pregnant women with preexisting CKD and preeclampsia have a higher incidence of premature delivery and restricted fetus growth than do women without CKD. “Most women with renal disease will have premature deliveries, and many will have smaller babies,” Dr. August said.

In some cases, renal disease becomes clinically apparent for the first time during pregnancy. Increased renal hemodynamics during pregnancy can unmask proteinuria. Close monitoring of blood pressure and urine during pregnancy may bring problems to light.

Renal evaluation of patients first suspected of having CKD during pregnancy is similar to that for patients who are not pregnant—serologic and function testing, and ultrasound.

A biopsy can even be performed, but it is common to avoid this measure during the third trimester of pregnancy because of anatomical and positioning issues.

Generally, only deteriorating kidney function or morbid nephritic syndrome is considered to be an indication for attempting a biopsy during pregnancy. Otherwise, it is preferred to wait until after delivery, Dr. August said.

It can be difficult to distinguish between intrinsic renal disease and preeclampsia. Renal disease can occur at any gestational age, but preeclampsia occurs after 20 weeks. Serum creatinine levels between 0.8 and 1.2 mg/dl are associated with preeclampsia, while levels of 1.5–1.8 mg/dL and higher are associated with renal disease.

“You almost never see azotemia in the setting of preeclampsia without proteinuria,” she said. In addition, intrinsic renal disease can occur with normal blood pressure, but a patient must be hypertensive to have preeclampsia.

Managing chronic renal disease during pregnancy requires a team approach that includes nephrologists. Dr. August recommends that patients be monitored frequently for preeclampsia—and for renal protection—blood pressure should be maintained within a slightly lower range than normal.

How Pregnancy Affects Kidney Function

Normal pregnancies have complex effects on the kidneys and on hemodynamics—changes that bear keeping in mind when evaluating pregnant patients with chronic kidney disease, Dr. August said.

During pregnancy, kidney size, blood flow, and glomerular filtration rate (GFR) all increase. GFR increases by as much as 50%, said Dr. August, of Cornell University in New York.

Renal vasodilation leads to increases in renin, urinary protein, aldosterone excretion, sodium and water reabsorption, glycosuria, and aminoaciduria. There are concomitant decreases in uric acid reabsorption and serum creatinine, sodium, and osmolarity. Normal serum sodium for a pregnant woman is in the 135–137 mmol/L range. Likewise, serum creatinine levels can be as low as 0.5 mg/dL and is usually 0.6 mg/dL; levels above 0.8 mg/dL indicate a decreased GFR, she said.

Uric acid levels also are lower in pregnant women—something to keep in mind when evaluating patients for possible preeclampsia, which causes serum uric acid levels to rise. In the second trimester, the normal uric acid level is usually not much higher than 3.5 mg/dL, and in the third trimester, it can go up as high as 4.5 mg/dL. “Anything higher than that is not quite normal,” Dr. August said.

Dilation of the urinary tract in pregnancy increases susceptibility to urinary tract infections. She recommends monthly screening for asymptomatic bacteriuria in pregnant women who are prone to urinary tract infections. Acute pyelonephritis can be much more serious than usual in pregnant women.

Hemodynamic changes during pregnancy include decreased blood pressure and increased cardiac output, heart rate, and respiratory rate. Some of these changes can actually be helpful for women with chronic kidney disease. Women who have been treated for hypertension and/or chronic kidney disease before pregnancy may require fewer medications during pregnancy.

DESTIN, FLA. — The diagnosis of joint hypermobility syndrome is probably getting missed in many cases, Alan J. Hakim, M.D., said at a rheumatology meeting sponsored by Virginia Commonwealth University.

Joint hypermobility syndrome (JHS) shares a number of features with related disorders, making it difficult to identify, but the correct diagnosis will make all the difference in patients' lives, said Dr. Hakim, a rheumatologist at Whipps Cross University Hospital in London.

JHS is thought to be related to Marfan syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta. In addition, JHS mimics fibromyalgia and chronic fatigue syndrome, and it can be difficult to distinguish JHS from these other conditions, he said.

JHS can involve a variety of musculoskeletal symptoms, from chronic pain and fatigue to soft-tissue and visceral injury, all in the presence of general joint laxity. Of the musculoskeletal symptoms, chronic noninflammatory joint pain or spinal pain is a key complaint. Other musculoskeletal symptoms include dislocation or subluxation of joints; ligament, tendon, or muscle overuse injuries; and deconditioning as a result of kinesphobia.

The other key clinical components include skin abnormalities such as excessive stretching of the skin and abnormal scarring, and psychosocial problems. This overall symptom complex can manifest in childhood, adolescence, or even early adulthood.

The prevalence of JHS in the general population ranges from 10% to 30%; the disorder is three times more common in women. JHS is more commonly seen in people of African and Asian ethnicity than in whites. There appears to be a strong genetic component, with approximately a 75% heritability rate of the phenotype.

Psychologic aspects are typical, because patients tend to feel anxious or depressed as a result of their chronic pain and disability. Panic disorders and phobias are four times more common in JHS patients. They may not be able work, adding to their sense of isolation. They avoid relationships and social activities. Sexual difficulties and reproductive concerns are common. They may feel frustrated with a medical system that has been unable to correctly diagnose them, Dr. Hakim explained.

Cardiorespiratory and bowel disturbances are also frequent and often disabling.

Related symptoms include palpitations, chest discomfort, lightheadedness, and presyncope. Bowel disturbances include nausea, dyspepsia, constipation, and diarrhea. All these symptoms are strongly associated with fatigue and anxiety.

There also appear to be proprioception and autonomic nervous system disturbances. Proprioceptive deficits have been shown to create to a vicious cycle, whereby diminished proprioception leads to altered neuromuscular control, causing altered mechanical loading, which leads to joint capsule and ligament damage, which in turn creates more of a tendency toward poor proprioception.

The Beighton nine-point scoring system, the conventional means of detecting hypermobility, assesses a patient's ability to perform five maneuvers on the right and left side of the body. Maneuvers include passive dorsiflexion of the fifth metacarpophalangeal joint to at least 90 degrees, opposition of the thumb to the volar aspect of the ipsilateral forearm, hyperextension of the elbow to at least 10 degrees, hyperextension of the knee to at least 10 degrees, and the ability to place the hands flat on the floor without bending the knees.

More recently, Dr. Hakim and colleagues have developed a simple five-item questionnaire to use as an adjunct for screening individuals with diffuse or localized musculoskeletal symptoms, in whom no clear-cut degenerative or inflammatory disease can be found. (See box.) The questionnaire is 80%–85% sensitive and 80%–90% specific, Dr. Hakim said.

Caring for these patients likewise requires a multidisciplinary approach, involving the patient, a physiotherapist, an occupational therapist, a psychologist, a nurse specialist, and a physician specialist, Dr. Hakim said at the meeting, also sponsored by the International Society for Clinical Densitometry.

The goals of rehabilitation are to reassure and educate these patients; develop core stability; enhance joint stability and proprioception; restore normal mobility, which for these patients may still mean hypermobility; reverse deconditioning by improving fitness and stamina; and develop behavioral strategies for coping and pain control.

Acute pain often responds to simple analgesics, NSAIDs, and local steroid injections. Chronic pain is more challenging to treat, in that anecdotal evidence suggests that simple analgesics are ineffective. Alternatives include serotonin/norepinephrine reuptake inhibitors, amitriptyline, tramadol, and gabapentin.

Cognitive behavior therapy has been shown to be helpful for improving quality of life and reducing pain and depression severity.

Physiotherapy alone does not appear effective, with JHS patients often reporting failure of this treatment.

In a study of 100 patients with back pain who participated in a rehabilitation program, Dr. Hakim and a colleague retrospectively assessed patients for JHS. Patients diagnosed with JHS were then matched for age and gender with patients not diagnosed with the disorder. Although both groups showed the same ability to walk prior to rehabilitation, those with JHS showed much less improvement immediately following the program and up to 3 months afterward.

The ability to stand from a sitting position improved to a lesser extent in JHS patients, compared with those without the disorder. However, the JHS patients had returned to baseline at 3 months' follow-up. The same was true for the ability to step up. Likewise, pain scores had not improved in the JHS group at 3 months, and those without the disorder showed marked improvement.

But physiotherapy can still be an important component of JHS treatment, he said. The ideal program would focus on developing core and peripheral stability, improving general posture, and improving proprioception. The pace of physiotherapy should take tissue fragility into account, because injuries in JHS patients can take longer to heal, and many patients need special care to overcome their fear of movement.

JHS can involve various symptoms, all in the presence of general joint laxity.

Skin abnormalities such as excessive stretching are typical. Photos courtesy Dr. Alan J. Hakim

Five Questions Can Help Identify Those With JHS

Can you now (or could you ever) place your hands flat on the floor without bending your knees?

Can you now (or could you ever) bend your thumb to touch your forearm?

As a child, did you amuse your friends by contorting your body into strange shapes, or could you do the splits?

As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?

Do you consider yourself double-jointed?

Source: Dr. Hakim

DESTIN, FLA. — The diagnosis of joint hypermobility syndrome is probably getting missed in many cases, Alan J. Hakim, M.D., said at a rheumatology meeting sponsored by Virginia Commonwealth University.

Joint hypermobility syndrome (JHS) shares a number of features with related disorders, making it difficult to identify, but the correct diagnosis will make all the difference in patients' lives, said Dr. Hakim, a rheumatologist at Whipps Cross University Hospital in London.

JHS is thought to be related to Marfan syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta. In addition, JHS mimics fibromyalgia and chronic fatigue syndrome, and it can be difficult to distinguish JHS from these other conditions, he said.

JHS can involve a variety of musculoskeletal symptoms, from chronic pain and fatigue to soft-tissue and visceral injury, all in the presence of general joint laxity. Of the musculoskeletal symptoms, chronic noninflammatory joint pain or spinal pain is a key complaint. Other musculoskeletal symptoms include dislocation or subluxation of joints; ligament, tendon, or muscle overuse injuries; and deconditioning as a result of kinesphobia.

The other key clinical components include skin abnormalities such as excessive stretching of the skin and abnormal scarring, and psychosocial problems. This overall symptom complex can manifest in childhood, adolescence, or even early adulthood.

The prevalence of JHS in the general population ranges from 10% to 30%; the disorder is three times more common in women. JHS is more commonly seen in people of African and Asian ethnicity than in whites. There appears to be a strong genetic component, with approximately a 75% heritability rate of the phenotype.

Psychologic aspects are typical, because patients tend to feel anxious or depressed as a result of their chronic pain and disability. Panic disorders and phobias are four times more common in JHS patients. They may not be able work, adding to their sense of isolation. They avoid relationships and social activities. Sexual difficulties and reproductive concerns are common. They may feel frustrated with a medical system that has been unable to correctly diagnose them, Dr. Hakim explained.

Cardiorespiratory and bowel disturbances are also frequent and often disabling.

Related symptoms include palpitations, chest discomfort, lightheadedness, and presyncope. Bowel disturbances include nausea, dyspepsia, constipation, and diarrhea. All these symptoms are strongly associated with fatigue and anxiety.

There also appear to be proprioception and autonomic nervous system disturbances. Proprioceptive deficits have been shown to create to a vicious cycle, whereby diminished proprioception leads to altered neuromuscular control, causing altered mechanical loading, which leads to joint capsule and ligament damage, which in turn creates more of a tendency toward poor proprioception.

The Beighton nine-point scoring system, the conventional means of detecting hypermobility, assesses a patient's ability to perform five maneuvers on the right and left side of the body. Maneuvers include passive dorsiflexion of the fifth metacarpophalangeal joint to at least 90 degrees, opposition of the thumb to the volar aspect of the ipsilateral forearm, hyperextension of the elbow to at least 10 degrees, hyperextension of the knee to at least 10 degrees, and the ability to place the hands flat on the floor without bending the knees.

More recently, Dr. Hakim and colleagues have developed a simple five-item questionnaire to use as an adjunct for screening individuals with diffuse or localized musculoskeletal symptoms, in whom no clear-cut degenerative or inflammatory disease can be found. (See box.) The questionnaire is 80%–85% sensitive and 80%–90% specific, Dr. Hakim said.

Caring for these patients likewise requires a multidisciplinary approach, involving the patient, a physiotherapist, an occupational therapist, a psychologist, a nurse specialist, and a physician specialist, Dr. Hakim said at the meeting, also sponsored by the International Society for Clinical Densitometry.

The goals of rehabilitation are to reassure and educate these patients; develop core stability; enhance joint stability and proprioception; restore normal mobility, which for these patients may still mean hypermobility; reverse deconditioning by improving fitness and stamina; and develop behavioral strategies for coping and pain control.

Acute pain often responds to simple analgesics, NSAIDs, and local steroid injections. Chronic pain is more challenging to treat, in that anecdotal evidence suggests that simple analgesics are ineffective. Alternatives include serotonin/norepinephrine reuptake inhibitors, amitriptyline, tramadol, and gabapentin.

Cognitive behavior therapy has been shown to be helpful for improving quality of life and reducing pain and depression severity.

Physiotherapy alone does not appear effective, with JHS patients often reporting failure of this treatment.

In a study of 100 patients with back pain who participated in a rehabilitation program, Dr. Hakim and a colleague retrospectively assessed patients for JHS. Patients diagnosed with JHS were then matched for age and gender with patients not diagnosed with the disorder. Although both groups showed the same ability to walk prior to rehabilitation, those with JHS showed much less improvement immediately following the program and up to 3 months afterward.

The ability to stand from a sitting position improved to a lesser extent in JHS patients, compared with those without the disorder. However, the JHS patients had returned to baseline at 3 months' follow-up. The same was true for the ability to step up. Likewise, pain scores had not improved in the JHS group at 3 months, and those without the disorder showed marked improvement.

But physiotherapy can still be an important component of JHS treatment, he said. The ideal program would focus on developing core and peripheral stability, improving general posture, and improving proprioception. The pace of physiotherapy should take tissue fragility into account, because injuries in JHS patients can take longer to heal, and many patients need special care to overcome their fear of movement.

JHS can involve various symptoms, all in the presence of general joint laxity.

Skin abnormalities such as excessive stretching are typical. Photos courtesy Dr. Alan J. Hakim

Five Questions Can Help Identify Those With JHS

Can you now (or could you ever) place your hands flat on the floor without bending your knees?

Can you now (or could you ever) bend your thumb to touch your forearm?

As a child, did you amuse your friends by contorting your body into strange shapes, or could you do the splits?

As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?

Do you consider yourself double-jointed?

Source: Dr. Hakim

DESTIN, FLA. — The diagnosis of joint hypermobility syndrome is probably getting missed in many cases, Alan J. Hakim, M.D., said at a rheumatology meeting sponsored by Virginia Commonwealth University.

Joint hypermobility syndrome (JHS) shares a number of features with related disorders, making it difficult to identify, but the correct diagnosis will make all the difference in patients' lives, said Dr. Hakim, a rheumatologist at Whipps Cross University Hospital in London.

JHS is thought to be related to Marfan syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta. In addition, JHS mimics fibromyalgia and chronic fatigue syndrome, and it can be difficult to distinguish JHS from these other conditions, he said.

JHS can involve a variety of musculoskeletal symptoms, from chronic pain and fatigue to soft-tissue and visceral injury, all in the presence of general joint laxity. Of the musculoskeletal symptoms, chronic noninflammatory joint pain or spinal pain is a key complaint. Other musculoskeletal symptoms include dislocation or subluxation of joints; ligament, tendon, or muscle overuse injuries; and deconditioning as a result of kinesphobia.

The other key clinical components include skin abnormalities such as excessive stretching of the skin and abnormal scarring, and psychosocial problems. This overall symptom complex can manifest in childhood, adolescence, or even early adulthood.

The prevalence of JHS in the general population ranges from 10% to 30%; the disorder is three times more common in women. JHS is more commonly seen in people of African and Asian ethnicity than in whites. There appears to be a strong genetic component, with approximately a 75% heritability rate of the phenotype.

Psychologic aspects are typical, because patients tend to feel anxious or depressed as a result of their chronic pain and disability. Panic disorders and phobias are four times more common in JHS patients. They may not be able work, adding to their sense of isolation. They avoid relationships and social activities. Sexual difficulties and reproductive concerns are common. They may feel frustrated with a medical system that has been unable to correctly diagnose them, Dr. Hakim explained.

Cardiorespiratory and bowel disturbances are also frequent and often disabling.

Related symptoms include palpitations, chest discomfort, lightheadedness, and presyncope. Bowel disturbances include nausea, dyspepsia, constipation, and diarrhea. All these symptoms are strongly associated with fatigue and anxiety.

There also appear to be proprioception and autonomic nervous system disturbances. Proprioceptive deficits have been shown to create to a vicious cycle, whereby diminished proprioception leads to altered neuromuscular control, causing altered mechanical loading, which leads to joint capsule and ligament damage, which in turn creates more of a tendency toward poor proprioception.

The Beighton nine-point scoring system, the conventional means of detecting hypermobility, assesses a patient's ability to perform five maneuvers on the right and left side of the body. Maneuvers include passive dorsiflexion of the fifth metacarpophalangeal joint to at least 90 degrees, opposition of the thumb to the volar aspect of the ipsilateral forearm, hyperextension of the elbow to at least 10 degrees, hyperextension of the knee to at least 10 degrees, and the ability to place the hands flat on the floor without bending the knees.

More recently, Dr. Hakim and colleagues have developed a simple five-item questionnaire to use as an adjunct for screening individuals with diffuse or localized musculoskeletal symptoms, in whom no clear-cut degenerative or inflammatory disease can be found. (See box.) The questionnaire is 80%–85% sensitive and 80%–90% specific, Dr. Hakim said.

Caring for these patients likewise requires a multidisciplinary approach, involving the patient, a physiotherapist, an occupational therapist, a psychologist, a nurse specialist, and a physician specialist, Dr. Hakim said at the meeting, also sponsored by the International Society for Clinical Densitometry.

The goals of rehabilitation are to reassure and educate these patients; develop core stability; enhance joint stability and proprioception; restore normal mobility, which for these patients may still mean hypermobility; reverse deconditioning by improving fitness and stamina; and develop behavioral strategies for coping and pain control.

Acute pain often responds to simple analgesics, NSAIDs, and local steroid injections. Chronic pain is more challenging to treat, in that anecdotal evidence suggests that simple analgesics are ineffective. Alternatives include serotonin/norepinephrine reuptake inhibitors, amitriptyline, tramadol, and gabapentin.

Cognitive behavior therapy has been shown to be helpful for improving quality of life and reducing pain and depression severity.

Physiotherapy alone does not appear effective, with JHS patients often reporting failure of this treatment.

In a study of 100 patients with back pain who participated in a rehabilitation program, Dr. Hakim and a colleague retrospectively assessed patients for JHS. Patients diagnosed with JHS were then matched for age and gender with patients not diagnosed with the disorder. Although both groups showed the same ability to walk prior to rehabilitation, those with JHS showed much less improvement immediately following the program and up to 3 months afterward.

The ability to stand from a sitting position improved to a lesser extent in JHS patients, compared with those without the disorder. However, the JHS patients had returned to baseline at 3 months' follow-up. The same was true for the ability to step up. Likewise, pain scores had not improved in the JHS group at 3 months, and those without the disorder showed marked improvement.

But physiotherapy can still be an important component of JHS treatment, he said. The ideal program would focus on developing core and peripheral stability, improving general posture, and improving proprioception. The pace of physiotherapy should take tissue fragility into account, because injuries in JHS patients can take longer to heal, and many patients need special care to overcome their fear of movement.

JHS can involve various symptoms, all in the presence of general joint laxity.

Skin abnormalities such as excessive stretching are typical. Photos courtesy Dr. Alan J. Hakim

Five Questions Can Help Identify Those With JHS

Can you now (or could you ever) place your hands flat on the floor without bending your knees?

Can you now (or could you ever) bend your thumb to touch your forearm?

As a child, did you amuse your friends by contorting your body into strange shapes, or could you do the splits?

As a child or teenager, did your shoulder or kneecap dislocate on more than one occasion?

Do you consider yourself double-jointed?

Source: Dr. Hakim

The Food and Drug Administration has issued an alert warning physicians and pharmacists that it has received reports of inadvertent oral administration of the aerolized drugs Foradil and Spiriva.

The agency has received information on 30 cases of oral administration of the two drugs. Most of these reports did not indicate an adverse event, but one did involve difficulty breathing following oral ingestion. Another case involved hospitalization resulting from exacerbation of chronic obstructive pulmonary disease (COPD).

The Foradil Aerolizer (formoterol inhalation powder), a long-acting, selective β-2 adrenoreceptor agonist manufactured by Novartis Pharmaceuticals Corp., is indicated for the scheduled maintenance therapy for asthma and COPD and for the prevention of exercise-induced bronchospasm on an as-needed basis. The Spiriva HandiHaler (tiotropium inhalation powder), a long-acting anticholinergic agent manufactured by Boehringer Ingelheim Corp., is indicated for the scheduled maintenance therapy for asthma and COPD.

The misadministration occurs because these capsules resemble those typically taken orally. In addition, the capsules are supplied in packages that do not prominently display “NOT FOR ORAL USE.” Swallowing instead of inhaling the capsules may lead to delayed onset of action, reduced efficacy, and inadequate drug delivery, the FDA warned.

The FDA is working with the manufacturers to resolve the problems. In the meantime, the agency recommends:

▸ Counsel patients about the potential for confusion and how to avoid it.

▸ Avoid dispensing the capsules for inhalation without the inhalation device.

▸ If the capsules for inhalation are dispensed separately as unit-dose capsules, affix a cautionary label or statement indicating “FOR INHALATION USE WITH SPECIAL INHALER ONLY.”

▸ Advise patients to store the capsules for inhalation together with the inhaler.

▸ Highlight the “FOR INHALATION USE ONLY” statement on the product package and container if possible.

The Food and Drug Administration has issued an alert warning physicians and pharmacists that it has received reports of inadvertent oral administration of the aerolized drugs Foradil and Spiriva.

The agency has received information on 30 cases of oral administration of the two drugs. Most of these reports did not indicate an adverse event, but one did involve difficulty breathing following oral ingestion. Another case involved hospitalization resulting from exacerbation of chronic obstructive pulmonary disease (COPD).

The Foradil Aerolizer (formoterol inhalation powder), a long-acting, selective β-2 adrenoreceptor agonist manufactured by Novartis Pharmaceuticals Corp., is indicated for the scheduled maintenance therapy for asthma and COPD and for the prevention of exercise-induced bronchospasm on an as-needed basis. The Spiriva HandiHaler (tiotropium inhalation powder), a long-acting anticholinergic agent manufactured by Boehringer Ingelheim Corp., is indicated for the scheduled maintenance therapy for asthma and COPD.

The misadministration occurs because these capsules resemble those typically taken orally. In addition, the capsules are supplied in packages that do not prominently display “NOT FOR ORAL USE.” Swallowing instead of inhaling the capsules may lead to delayed onset of action, reduced efficacy, and inadequate drug delivery, the FDA warned.

The FDA is working with the manufacturers to resolve the problems. In the meantime, the agency recommends:

▸ Counsel patients about the potential for confusion and how to avoid it.

▸ Avoid dispensing the capsules for inhalation without the inhalation device.

▸ If the capsules for inhalation are dispensed separately as unit-dose capsules, affix a cautionary label or statement indicating “FOR INHALATION USE WITH SPECIAL INHALER ONLY.”

▸ Advise patients to store the capsules for inhalation together with the inhaler.

▸ Highlight the “FOR INHALATION USE ONLY” statement on the product package and container if possible.

The Food and Drug Administration has issued an alert warning physicians and pharmacists that it has received reports of inadvertent oral administration of the aerolized drugs Foradil and Spiriva.

The agency has received information on 30 cases of oral administration of the two drugs. Most of these reports did not indicate an adverse event, but one did involve difficulty breathing following oral ingestion. Another case involved hospitalization resulting from exacerbation of chronic obstructive pulmonary disease (COPD).

The Foradil Aerolizer (formoterol inhalation powder), a long-acting, selective β-2 adrenoreceptor agonist manufactured by Novartis Pharmaceuticals Corp., is indicated for the scheduled maintenance therapy for asthma and COPD and for the prevention of exercise-induced bronchospasm on an as-needed basis. The Spiriva HandiHaler (tiotropium inhalation powder), a long-acting anticholinergic agent manufactured by Boehringer Ingelheim Corp., is indicated for the scheduled maintenance therapy for asthma and COPD.

The misadministration occurs because these capsules resemble those typically taken orally. In addition, the capsules are supplied in packages that do not prominently display “NOT FOR ORAL USE.” Swallowing instead of inhaling the capsules may lead to delayed onset of action, reduced efficacy, and inadequate drug delivery, the FDA warned.

The FDA is working with the manufacturers to resolve the problems. In the meantime, the agency recommends:

▸ Counsel patients about the potential for confusion and how to avoid it.

▸ Avoid dispensing the capsules for inhalation without the inhalation device.

▸ If the capsules for inhalation are dispensed separately as unit-dose capsules, affix a cautionary label or statement indicating “FOR INHALATION USE WITH SPECIAL INHALER ONLY.”

▸ Advise patients to store the capsules for inhalation together with the inhaler.

▸ Highlight the “FOR INHALATION USE ONLY” statement on the product package and container if possible.