Mary Ann Moon

Major Finding: Of psoriasis patients, 40% have the metabolic syndrome, approximately double the rate found in adults who do not have psoriasis.

Data Source: Analysis of data from a cross-sectional health survey of a nationally representative random sample of 6,549 U.S. adults.

Disclosures: This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and C-reactive protein levels.

“Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis,” reported Dr. Thorvardur Jon Love of Brigham and Women's Hospital, Boston, and his associates.

“Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis,” according to Dr. Love and his coinvestigators.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients.

In particular, patients with severe psoriasis have been reported to be at an increased risk for myocardial infarction, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis.

The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When the investigators removed CRP levels from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 [doi:10.1001/archderma tol.2010.370]).

“When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% confidence interval, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis,” according to the researchers.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, which was present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that “a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications,” Dr. Love and his colleagues wrote.

This association with the metabolic syndrome also should be considered when choosing therapy for psoriasis. “For example, tumor necrosis factor blockers may decrease insulin resistance,” they added.

Major Finding: Of psoriasis patients, 40% have the metabolic syndrome, approximately double the rate found in adults who do not have psoriasis.

Data Source: Analysis of data from a cross-sectional health survey of a nationally representative random sample of 6,549 U.S. adults.

Disclosures: This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and C-reactive protein levels.

“Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis,” reported Dr. Thorvardur Jon Love of Brigham and Women's Hospital, Boston, and his associates.

“Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis,” according to Dr. Love and his coinvestigators.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients.

In particular, patients with severe psoriasis have been reported to be at an increased risk for myocardial infarction, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis.

The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When the investigators removed CRP levels from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 [doi:10.1001/archderma tol.2010.370]).

“When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% confidence interval, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis,” according to the researchers.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, which was present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that “a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications,” Dr. Love and his colleagues wrote.

This association with the metabolic syndrome also should be considered when choosing therapy for psoriasis. “For example, tumor necrosis factor blockers may decrease insulin resistance,” they added.

Major Finding: Of psoriasis patients, 40% have the metabolic syndrome, approximately double the rate found in adults who do not have psoriasis.

Data Source: Analysis of data from a cross-sectional health survey of a nationally representative random sample of 6,549 U.S. adults.

Disclosures: This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and C-reactive protein levels.

“Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis,” reported Dr. Thorvardur Jon Love of Brigham and Women's Hospital, Boston, and his associates.

“Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis,” according to Dr. Love and his coinvestigators.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients.

In particular, patients with severe psoriasis have been reported to be at an increased risk for myocardial infarction, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis.

The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When the investigators removed CRP levels from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 [doi:10.1001/archderma tol.2010.370]).

“When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% confidence interval, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis,” according to the researchers.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, which was present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that “a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications,” Dr. Love and his colleagues wrote.

This association with the metabolic syndrome also should be considered when choosing therapy for psoriasis. “For example, tumor necrosis factor blockers may decrease insulin resistance,” they added.

Major Finding: African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites.

Data Source: Single-center, observational cohort study of 1,024 white and 66 black patients with parkinsonism.

Disclosures: Dr. Hemming's associates reported ties to numerous manufacturers of drugs for Parkinson's disease.

African Americans with parkinsonism have more severe symptoms, more disability, and poorer symptom management than whites, according to a report published online Dec. 13.

These disparities cannot be attributed to differences between the races in age, cognitive function, or disease duration because these factors were comparable between blacks and whites in this single-center study. It appears that the racial disparities “may be explained by delayed diagnosis, referral patterns, access to care, economic factors, or a combination of all of these,” wrote Dr. J. Patrick Hemming and his associates at the University of Maryland, Baltimore (Arch. Neurol. 2010 Dec. 13 [doi: 10.1001/archneurol.2010.326]).

Independently of race, both lower socioeconomic status and lower education level also were associated with more severe signs and symptoms, greater disability, and poorer management of parkinsonism in this study.

“Studies in different patient populations and geographic locations are necessary to confirm these findings,” they noted.

Dr. Hemming and his colleagues evaluated 1,090 patients with parkinsonism who were participating in a quality of life assessment at the university's movement disorders center between 2003 and 2008. A total of 66 patients were African American and the rest were white; the researchers were unable to assess patients of other racial or ethnic backgrounds.

African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites (53 vs. 42.8).

The investigators called this finding a “striking difference that may influence mortality” because a previous study found that a one-point increase on the UPDRS was associated with a relative risk ratio of 1.1 for death within 7 years.

African Americans also had worse scores than did whites on a modified version of the Older Americans Resource and Services (OARS) disability subscale, which measures the level of difficulty in performing 14 daily activities.

Significantly fewer African Americans were prescribed antiparkinson medications than were whites (62% vs. 78%), and fewer African Americans also were receiving new dopaminergic agents (21% vs. 41%). In contrast, significantly more black patients used antipsychotic medications than did whites (13% vs. 6%).

When the data were analyzed by income and education level after controlling for race, UPDRS and OARS scores were significantly higher among patients who earned less than $30,000 per year than among those who earned more than $70,000 per year.

Similarly, low-income patients used newer dopaminergic agents significantly less often than did high-income patients (30% vs. 47%). Low-income patients, however, were more likely to be prescribed antidepressants, antipsychotics, and antidementia agents.

Newer dopamine agonists were prescribed significantly less often for patients with less than a college education (35%) than for those with a college education (43%).

In contrast, antipsychotics were approximately twice as likely to be prescribed for patients without a college education (8.4%) than they were for those with a college education (4.7%).

These findings reinforce the conclusion that racial disparities in the management of parkinsonism are not solely due to differences in income or education level, but that race itself is a significant independent factor, the researchers said.

Major Finding: African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites.

Data Source: Single-center, observational cohort study of 1,024 white and 66 black patients with parkinsonism.

Disclosures: Dr. Hemming's associates reported ties to numerous manufacturers of drugs for Parkinson's disease.

African Americans with parkinsonism have more severe symptoms, more disability, and poorer symptom management than whites, according to a report published online Dec. 13.

These disparities cannot be attributed to differences between the races in age, cognitive function, or disease duration because these factors were comparable between blacks and whites in this single-center study. It appears that the racial disparities “may be explained by delayed diagnosis, referral patterns, access to care, economic factors, or a combination of all of these,” wrote Dr. J. Patrick Hemming and his associates at the University of Maryland, Baltimore (Arch. Neurol. 2010 Dec. 13 [doi: 10.1001/archneurol.2010.326]).

Independently of race, both lower socioeconomic status and lower education level also were associated with more severe signs and symptoms, greater disability, and poorer management of parkinsonism in this study.

“Studies in different patient populations and geographic locations are necessary to confirm these findings,” they noted.

Dr. Hemming and his colleagues evaluated 1,090 patients with parkinsonism who were participating in a quality of life assessment at the university's movement disorders center between 2003 and 2008. A total of 66 patients were African American and the rest were white; the researchers were unable to assess patients of other racial or ethnic backgrounds.

African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites (53 vs. 42.8).

The investigators called this finding a “striking difference that may influence mortality” because a previous study found that a one-point increase on the UPDRS was associated with a relative risk ratio of 1.1 for death within 7 years.

African Americans also had worse scores than did whites on a modified version of the Older Americans Resource and Services (OARS) disability subscale, which measures the level of difficulty in performing 14 daily activities.

Significantly fewer African Americans were prescribed antiparkinson medications than were whites (62% vs. 78%), and fewer African Americans also were receiving new dopaminergic agents (21% vs. 41%). In contrast, significantly more black patients used antipsychotic medications than did whites (13% vs. 6%).

When the data were analyzed by income and education level after controlling for race, UPDRS and OARS scores were significantly higher among patients who earned less than $30,000 per year than among those who earned more than $70,000 per year.

Similarly, low-income patients used newer dopaminergic agents significantly less often than did high-income patients (30% vs. 47%). Low-income patients, however, were more likely to be prescribed antidepressants, antipsychotics, and antidementia agents.

Newer dopamine agonists were prescribed significantly less often for patients with less than a college education (35%) than for those with a college education (43%).

In contrast, antipsychotics were approximately twice as likely to be prescribed for patients without a college education (8.4%) than they were for those with a college education (4.7%).

These findings reinforce the conclusion that racial disparities in the management of parkinsonism are not solely due to differences in income or education level, but that race itself is a significant independent factor, the researchers said.

Major Finding: African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites.

Data Source: Single-center, observational cohort study of 1,024 white and 66 black patients with parkinsonism.

Disclosures: Dr. Hemming's associates reported ties to numerous manufacturers of drugs for Parkinson's disease.

African Americans with parkinsonism have more severe symptoms, more disability, and poorer symptom management than whites, according to a report published online Dec. 13.

These disparities cannot be attributed to differences between the races in age, cognitive function, or disease duration because these factors were comparable between blacks and whites in this single-center study. It appears that the racial disparities “may be explained by delayed diagnosis, referral patterns, access to care, economic factors, or a combination of all of these,” wrote Dr. J. Patrick Hemming and his associates at the University of Maryland, Baltimore (Arch. Neurol. 2010 Dec. 13 [doi: 10.1001/archneurol.2010.326]).

Independently of race, both lower socioeconomic status and lower education level also were associated with more severe signs and symptoms, greater disability, and poorer management of parkinsonism in this study.

“Studies in different patient populations and geographic locations are necessary to confirm these findings,” they noted.

Dr. Hemming and his colleagues evaluated 1,090 patients with parkinsonism who were participating in a quality of life assessment at the university's movement disorders center between 2003 and 2008. A total of 66 patients were African American and the rest were white; the researchers were unable to assess patients of other racial or ethnic backgrounds.

African Americans scored an average of 10 points higher on the Unified Parkinson's Disease Rating Scale than did whites (53 vs. 42.8).

The investigators called this finding a “striking difference that may influence mortality” because a previous study found that a one-point increase on the UPDRS was associated with a relative risk ratio of 1.1 for death within 7 years.

African Americans also had worse scores than did whites on a modified version of the Older Americans Resource and Services (OARS) disability subscale, which measures the level of difficulty in performing 14 daily activities.

Significantly fewer African Americans were prescribed antiparkinson medications than were whites (62% vs. 78%), and fewer African Americans also were receiving new dopaminergic agents (21% vs. 41%). In contrast, significantly more black patients used antipsychotic medications than did whites (13% vs. 6%).

When the data were analyzed by income and education level after controlling for race, UPDRS and OARS scores were significantly higher among patients who earned less than $30,000 per year than among those who earned more than $70,000 per year.

Similarly, low-income patients used newer dopaminergic agents significantly less often than did high-income patients (30% vs. 47%). Low-income patients, however, were more likely to be prescribed antidepressants, antipsychotics, and antidementia agents.

Newer dopamine agonists were prescribed significantly less often for patients with less than a college education (35%) than for those with a college education (43%).

In contrast, antipsychotics were approximately twice as likely to be prescribed for patients without a college education (8.4%) than they were for those with a college education (4.7%).

These findings reinforce the conclusion that racial disparities in the management of parkinsonism are not solely due to differences in income or education level, but that race itself is a significant independent factor, the researchers said.

For opioid-dependent women who are pregnant, buprenorphine appears to offer an effective, safe first-line alternative to methadone, according to a report in the Dec. 9 issue of the New England Journal of Medicine.

In a randomized clinical trial comparing pregnancy outcomes among women seeking treatment for opioid dependence, infants exposed in utero to buprenorphine developed significantly less severe neonatal abstinence syndrome than did infants exposed in utero to methadone, said Hendrée E. Jones, Ph.D., of the department of psychiatry and behavioral sciences and the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, and her associates.

The study involved 175 women aged 18-41 years who were at 6-30 weeks’ gestation when they entered treatment for opioid dependence at eight sites in the United States, Austria, and Canada. Eighty-six were randomly assigned to receive oral buprenorphine and 89 to receive oral methadone in a double-blind fashion.

After delivery, their neonates were assessed for signs and symptoms of neonatal abstinence syndrome (NAS) twice a day for at least 10 days.

There were five primary neonatal outcomes. Three of these – percentage of neonates requiring NAS treatment, peak NAS scores, and head circumference – did not differ between the two study groups. However, two of the five primary outcomes – amount of morphine required to treat NAS and length of hospital stay – favored the infants in the buprenorphine group. On average, infants exposed to buprenorphine required 89% less morphine and spent 43% less time in the hospital (10 days vs. 17.5 days) than infants exposed to methadone.

"The benefits of buprenorphine in reducing the severity of NAS among neonates with this complication suggest that it should be considered a first-line treatment option in pregnancy," Dr. Jones and her colleagues said (N. Engl. J. Med. 2010;363:2320-31).

Neonates of mothers who received buprenorphine also required a significantly shorter period of treatment for NAS (4.1 days) than did neonates of mothers who received methadone, who required 9.9 days of treatment for NAS, they reported.

There were no differences in any maternal outcomes between women who took buprenorphine and those who took methadone.

Despite the comparable or even superior efficacy and safety of buprenorphine, there was one important drawback with the therapy: Women were more likely to discontinue treatment for opioid dependency with buprenorphine (33%) than with methadone (18%). Most (71%) of the women in the buprenorphine group who discontinued treatment cited "dissatisfaction" with the drug as their reason, while only 13% of those in the methadone group did so.

The benefits of buprenorphine therapy "must be considered in light of the markedly different rates of attrition," Dr. Jones and her associates said. Future research should focus on reducing this "dissatisfaction" as well as on identifying "subpopulations of pregnant patients who are more likely to have a response to one medication than to the other," they added.

This study was funded by grants from the National Institute on Drug Abuse. Buprenorphine tablets and the associated placebo were supplied by Reckitt Benckiser. Dr. Jones had no financial conflicts to disclose. One of Dr. Jones’ associates reported ties to a number of drug companies, and others had or were seeking federal grants.

For opioid-dependent women who are pregnant, buprenorphine appears to offer an effective, safe first-line alternative to methadone, according to a report in the Dec. 9 issue of the New England Journal of Medicine.

In a randomized clinical trial comparing pregnancy outcomes among women seeking treatment for opioid dependence, infants exposed in utero to buprenorphine developed significantly less severe neonatal abstinence syndrome than did infants exposed in utero to methadone, said Hendrée E. Jones, Ph.D., of the department of psychiatry and behavioral sciences and the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, and her associates.

The study involved 175 women aged 18-41 years who were at 6-30 weeks’ gestation when they entered treatment for opioid dependence at eight sites in the United States, Austria, and Canada. Eighty-six were randomly assigned to receive oral buprenorphine and 89 to receive oral methadone in a double-blind fashion.

After delivery, their neonates were assessed for signs and symptoms of neonatal abstinence syndrome (NAS) twice a day for at least 10 days.

There were five primary neonatal outcomes. Three of these – percentage of neonates requiring NAS treatment, peak NAS scores, and head circumference – did not differ between the two study groups. However, two of the five primary outcomes – amount of morphine required to treat NAS and length of hospital stay – favored the infants in the buprenorphine group. On average, infants exposed to buprenorphine required 89% less morphine and spent 43% less time in the hospital (10 days vs. 17.5 days) than infants exposed to methadone.

"The benefits of buprenorphine in reducing the severity of NAS among neonates with this complication suggest that it should be considered a first-line treatment option in pregnancy," Dr. Jones and her colleagues said (N. Engl. J. Med. 2010;363:2320-31).

Neonates of mothers who received buprenorphine also required a significantly shorter period of treatment for NAS (4.1 days) than did neonates of mothers who received methadone, who required 9.9 days of treatment for NAS, they reported.

There were no differences in any maternal outcomes between women who took buprenorphine and those who took methadone.

Despite the comparable or even superior efficacy and safety of buprenorphine, there was one important drawback with the therapy: Women were more likely to discontinue treatment for opioid dependency with buprenorphine (33%) than with methadone (18%). Most (71%) of the women in the buprenorphine group who discontinued treatment cited "dissatisfaction" with the drug as their reason, while only 13% of those in the methadone group did so.

The benefits of buprenorphine therapy "must be considered in light of the markedly different rates of attrition," Dr. Jones and her associates said. Future research should focus on reducing this "dissatisfaction" as well as on identifying "subpopulations of pregnant patients who are more likely to have a response to one medication than to the other," they added.

This study was funded by grants from the National Institute on Drug Abuse. Buprenorphine tablets and the associated placebo were supplied by Reckitt Benckiser. Dr. Jones had no financial conflicts to disclose. One of Dr. Jones’ associates reported ties to a number of drug companies, and others had or were seeking federal grants.

For opioid-dependent women who are pregnant, buprenorphine appears to offer an effective, safe first-line alternative to methadone, according to a report in the Dec. 9 issue of the New England Journal of Medicine.

In a randomized clinical trial comparing pregnancy outcomes among women seeking treatment for opioid dependence, infants exposed in utero to buprenorphine developed significantly less severe neonatal abstinence syndrome than did infants exposed in utero to methadone, said Hendrée E. Jones, Ph.D., of the department of psychiatry and behavioral sciences and the department of obstetrics and gynecology at Johns Hopkins University, Baltimore, and her associates.

The study involved 175 women aged 18-41 years who were at 6-30 weeks’ gestation when they entered treatment for opioid dependence at eight sites in the United States, Austria, and Canada. Eighty-six were randomly assigned to receive oral buprenorphine and 89 to receive oral methadone in a double-blind fashion.

After delivery, their neonates were assessed for signs and symptoms of neonatal abstinence syndrome (NAS) twice a day for at least 10 days.

There were five primary neonatal outcomes. Three of these – percentage of neonates requiring NAS treatment, peak NAS scores, and head circumference – did not differ between the two study groups. However, two of the five primary outcomes – amount of morphine required to treat NAS and length of hospital stay – favored the infants in the buprenorphine group. On average, infants exposed to buprenorphine required 89% less morphine and spent 43% less time in the hospital (10 days vs. 17.5 days) than infants exposed to methadone.

"The benefits of buprenorphine in reducing the severity of NAS among neonates with this complication suggest that it should be considered a first-line treatment option in pregnancy," Dr. Jones and her colleagues said (N. Engl. J. Med. 2010;363:2320-31).

Neonates of mothers who received buprenorphine also required a significantly shorter period of treatment for NAS (4.1 days) than did neonates of mothers who received methadone, who required 9.9 days of treatment for NAS, they reported.

There were no differences in any maternal outcomes between women who took buprenorphine and those who took methadone.

Despite the comparable or even superior efficacy and safety of buprenorphine, there was one important drawback with the therapy: Women were more likely to discontinue treatment for opioid dependency with buprenorphine (33%) than with methadone (18%). Most (71%) of the women in the buprenorphine group who discontinued treatment cited "dissatisfaction" with the drug as their reason, while only 13% of those in the methadone group did so.

The benefits of buprenorphine therapy "must be considered in light of the markedly different rates of attrition," Dr. Jones and her associates said. Future research should focus on reducing this "dissatisfaction" as well as on identifying "subpopulations of pregnant patients who are more likely to have a response to one medication than to the other," they added.

This study was funded by grants from the National Institute on Drug Abuse. Buprenorphine tablets and the associated placebo were supplied by Reckitt Benckiser. Dr. Jones had no financial conflicts to disclose. One of Dr. Jones’ associates reported ties to a number of drug companies, and others had or were seeking federal grants.

Adolescents living in rural areas of the United States are more likely to abuse prescription drugs than are those living in urban areas, according to a report published online in the Archives of Pediatrics and Adolescent Medicine.

Even after study data were adjusted to account for differences between rural and urban adolescents in sociodemographics, health factors, and the abuse of other drugs, researchers found that residency in a rural area was independently associated with a significantly higher prevalence of prescription drug abuse. This pattern was not seen for abuse of any other substances, such as marijuana, cocaine, hallucinogens, inhalants, or alcohol, said Jennifer R. Havens, Ph.D., of the center on drug and alcohol research at the University of Kentucky, Lexington, and her associates.

Nationally, the rate of nonmedical use of prescription drugs ballooned by 212% between 1992 and 2003 among adolescents, to a rate nearly three times higher than that among people older than 18 years.

Many studies have assessed substance abuse among urban adolescents, but few have examined abuse among their rural counterparts. Moreover, the conclusions of the urban studies may not be generalizable to rural areas "owing to a unique set of contextual influences" that affect rural life, the investigators noted.

In particular, "the decimation of rural economies, precipitated by declines in the agricultural, manufacturing, and mining industries, and evidenced by high rates of unemployment," has contributed to profound economic and social decline in rural areas. Physical isolation, lack of insurance coverage, unavailability of local detoxification and psychiatric services, mistrust of the medical establishment, and the perceived stigma associated with seeking health care (especially mental health care) are all obstacles that disproportionately affect rural patients, they said.

To assess drug use among rural youths, Dr. Havens and her colleagues used data from the federal government’s National Survey on Drug Use and Health, an annual survey of a nationally representative sample of adolescents and adults that measures the prevalence and correlates of substance abuse. For this analysis, they included self-reported responses from 17,842 boys and girls aged 12-17 years.

Compared with respondents from urban and suburban areas, those from rural areas had significantly less income, were significantly more likely to have dropped out of school, and were significantly less likely to report excellent overall health. The prevalence of major depressive episodes was the same across the three geographic areas.

Adolescents residing in rural areas were 26% more likely than those in urban areas to report recent nonmedical use of prescription drugs, particularly pain relievers and tranquilizers. In all, 13% of rural adolescents reported any lifetime abuse of prescription drugs, compared with only 10% of urban adolescents, the researchers said (Arch. Pediatr. Adolesc. Med. 2010 Nov. 1 [doi:10.1001/archpediatrics.2010.217]).

Among the rural adolescents, nonmedical use of prescription drugs strongly correlated with dropping out of school and with having only one parent. Rural adolescents were 32% less likely to use illicit prescription drugs if they lived in a two-parent household than if they lived with only one parent.

It would seem, then, that interventions aimed at improving school retention and involving family members in adolescents’ lives might help prevent or reduce nonmedical prescription drug use in this population, Dr. Havens and her associates said.

Rural youths with a history of one or more major depressive episodes were more likely to abuse prescription drugs than were other youths, suggesting that they have poorer access to medical and/or psychiatric care than do adolescents residing in urban or suburban areas. This points to another potential source of intervention, "namely school-based counseling for mental health and substance abuse," the researchers added.

A particularly interesting finding was that the odds that a rural adolescent would abuse prescription drugs increased as that individual’s self-assessed health status declined. Other studies have shown that the prevalence of chronic pain is higher in rural areas, and that rural patients are less likely to have their health care needs met and more likely to forgo needed health care. This suggests that rural adolescents may have higher rates of self-medicating for pain, and that improving their health care could reduce the rate of self-medication, Dr. Havens and her colleagues said.

Future research should examine factors associated with use of pain relievers and tranquilizers among rural adolescents as "a next logical step," they added.

No financial conflicts of interest were reported.

Adolescents living in rural areas of the United States are more likely to abuse prescription drugs than are those living in urban areas, according to a report published online in the Archives of Pediatrics and Adolescent Medicine.

Even after study data were adjusted to account for differences between rural and urban adolescents in sociodemographics, health factors, and the abuse of other drugs, researchers found that residency in a rural area was independently associated with a significantly higher prevalence of prescription drug abuse. This pattern was not seen for abuse of any other substances, such as marijuana, cocaine, hallucinogens, inhalants, or alcohol, said Jennifer R. Havens, Ph.D., of the center on drug and alcohol research at the University of Kentucky, Lexington, and her associates.

Nationally, the rate of nonmedical use of prescription drugs ballooned by 212% between 1992 and 2003 among adolescents, to a rate nearly three times higher than that among people older than 18 years.

Many studies have assessed substance abuse among urban adolescents, but few have examined abuse among their rural counterparts. Moreover, the conclusions of the urban studies may not be generalizable to rural areas "owing to a unique set of contextual influences" that affect rural life, the investigators noted.

In particular, "the decimation of rural economies, precipitated by declines in the agricultural, manufacturing, and mining industries, and evidenced by high rates of unemployment," has contributed to profound economic and social decline in rural areas. Physical isolation, lack of insurance coverage, unavailability of local detoxification and psychiatric services, mistrust of the medical establishment, and the perceived stigma associated with seeking health care (especially mental health care) are all obstacles that disproportionately affect rural patients, they said.

To assess drug use among rural youths, Dr. Havens and her colleagues used data from the federal government’s National Survey on Drug Use and Health, an annual survey of a nationally representative sample of adolescents and adults that measures the prevalence and correlates of substance abuse. For this analysis, they included self-reported responses from 17,842 boys and girls aged 12-17 years.

Compared with respondents from urban and suburban areas, those from rural areas had significantly less income, were significantly more likely to have dropped out of school, and were significantly less likely to report excellent overall health. The prevalence of major depressive episodes was the same across the three geographic areas.

Adolescents residing in rural areas were 26% more likely than those in urban areas to report recent nonmedical use of prescription drugs, particularly pain relievers and tranquilizers. In all, 13% of rural adolescents reported any lifetime abuse of prescription drugs, compared with only 10% of urban adolescents, the researchers said (Arch. Pediatr. Adolesc. Med. 2010 Nov. 1 [doi:10.1001/archpediatrics.2010.217]).

Among the rural adolescents, nonmedical use of prescription drugs strongly correlated with dropping out of school and with having only one parent. Rural adolescents were 32% less likely to use illicit prescription drugs if they lived in a two-parent household than if they lived with only one parent.

It would seem, then, that interventions aimed at improving school retention and involving family members in adolescents’ lives might help prevent or reduce nonmedical prescription drug use in this population, Dr. Havens and her associates said.

Rural youths with a history of one or more major depressive episodes were more likely to abuse prescription drugs than were other youths, suggesting that they have poorer access to medical and/or psychiatric care than do adolescents residing in urban or suburban areas. This points to another potential source of intervention, "namely school-based counseling for mental health and substance abuse," the researchers added.

A particularly interesting finding was that the odds that a rural adolescent would abuse prescription drugs increased as that individual’s self-assessed health status declined. Other studies have shown that the prevalence of chronic pain is higher in rural areas, and that rural patients are less likely to have their health care needs met and more likely to forgo needed health care. This suggests that rural adolescents may have higher rates of self-medicating for pain, and that improving their health care could reduce the rate of self-medication, Dr. Havens and her colleagues said.

Future research should examine factors associated with use of pain relievers and tranquilizers among rural adolescents as "a next logical step," they added.

No financial conflicts of interest were reported.

Adolescents living in rural areas of the United States are more likely to abuse prescription drugs than are those living in urban areas, according to a report published online in the Archives of Pediatrics and Adolescent Medicine.

Even after study data were adjusted to account for differences between rural and urban adolescents in sociodemographics, health factors, and the abuse of other drugs, researchers found that residency in a rural area was independently associated with a significantly higher prevalence of prescription drug abuse. This pattern was not seen for abuse of any other substances, such as marijuana, cocaine, hallucinogens, inhalants, or alcohol, said Jennifer R. Havens, Ph.D., of the center on drug and alcohol research at the University of Kentucky, Lexington, and her associates.

Nationally, the rate of nonmedical use of prescription drugs ballooned by 212% between 1992 and 2003 among adolescents, to a rate nearly three times higher than that among people older than 18 years.

Many studies have assessed substance abuse among urban adolescents, but few have examined abuse among their rural counterparts. Moreover, the conclusions of the urban studies may not be generalizable to rural areas "owing to a unique set of contextual influences" that affect rural life, the investigators noted.

In particular, "the decimation of rural economies, precipitated by declines in the agricultural, manufacturing, and mining industries, and evidenced by high rates of unemployment," has contributed to profound economic and social decline in rural areas. Physical isolation, lack of insurance coverage, unavailability of local detoxification and psychiatric services, mistrust of the medical establishment, and the perceived stigma associated with seeking health care (especially mental health care) are all obstacles that disproportionately affect rural patients, they said.

To assess drug use among rural youths, Dr. Havens and her colleagues used data from the federal government’s National Survey on Drug Use and Health, an annual survey of a nationally representative sample of adolescents and adults that measures the prevalence and correlates of substance abuse. For this analysis, they included self-reported responses from 17,842 boys and girls aged 12-17 years.

Compared with respondents from urban and suburban areas, those from rural areas had significantly less income, were significantly more likely to have dropped out of school, and were significantly less likely to report excellent overall health. The prevalence of major depressive episodes was the same across the three geographic areas.

Adolescents residing in rural areas were 26% more likely than those in urban areas to report recent nonmedical use of prescription drugs, particularly pain relievers and tranquilizers. In all, 13% of rural adolescents reported any lifetime abuse of prescription drugs, compared with only 10% of urban adolescents, the researchers said (Arch. Pediatr. Adolesc. Med. 2010 Nov. 1 [doi:10.1001/archpediatrics.2010.217]).

Among the rural adolescents, nonmedical use of prescription drugs strongly correlated with dropping out of school and with having only one parent. Rural adolescents were 32% less likely to use illicit prescription drugs if they lived in a two-parent household than if they lived with only one parent.

It would seem, then, that interventions aimed at improving school retention and involving family members in adolescents’ lives might help prevent or reduce nonmedical prescription drug use in this population, Dr. Havens and her associates said.

Rural youths with a history of one or more major depressive episodes were more likely to abuse prescription drugs than were other youths, suggesting that they have poorer access to medical and/or psychiatric care than do adolescents residing in urban or suburban areas. This points to another potential source of intervention, "namely school-based counseling for mental health and substance abuse," the researchers added.

A particularly interesting finding was that the odds that a rural adolescent would abuse prescription drugs increased as that individual’s self-assessed health status declined. Other studies have shown that the prevalence of chronic pain is higher in rural areas, and that rural patients are less likely to have their health care needs met and more likely to forgo needed health care. This suggests that rural adolescents may have higher rates of self-medicating for pain, and that improving their health care could reduce the rate of self-medication, Dr. Havens and her colleagues said.

Future research should examine factors associated with use of pain relievers and tranquilizers among rural adolescents as "a next logical step," they added.

No financial conflicts of interest were reported.

Toddlers at risk for autism spectrum disorders preferred to look at geometric patterns more than social images in a 1-minute experiment, in contrast to developmentally delayed and developmentally normal toddlers, according to a report published online Sept. 6 in the Archives of General Psychiatry.

"When the percentage of time a toddler spent fixating on geometric patterns was 69% or greater, the positive predictive validity for accurately classifying that toddler as having an autism spectrum disorder was 100%," said Karen Pierce, Ph.D., department of neurosciences, Autism Center of Excellence, University of California, San Diego, and her associates.

Other investigators have used eye-tracking technology to assess differences between autistic and other infants and young children in response to pictures of faces. However, "given the active pace of brain development during the infancy period combined with high intersubject variability of eye tracking patterns to faces during this time, examining the percentage of time an infant attends to the eye region of a face may not be stable enough to make diagnostically predictive claims," Dr. Pierce and her colleagues noted.

"An alternative method to investigate early indicators of autism is to measure a very simple behavior: preference."

Developmentally normal infants and toddlers are known to show a distinct preference for faces when presented with two different images to look at. "What infants prefer to look at when given a choice between two images may turn out to be a more clearly observable indicator of risk than how they look at a single image," the researchers said.

To test this hypothesis, they used eye-tracking technology to monitor subjects’ gaze when watching split-screen moving images of children dancing or performing yoga on one side (dynamic social images) and moving geometric shapes on the other (dynamic geometric images). This movie contained 28 separate scenes, with each scene varying in duration from 2 to 4 seconds, for a total presentation time of 1 minute.

The study subjects were 110 toddlers (aged 14-42 months). A total of 37 children had autism spectrum disorders (27 with autistic disorder, 9 with pervasive developmental delay not otherwise specified, and 1 with autism spectrum features). Another 51 children, matched for age and gender, were developmentally normal. And 22 children who had developmental delay (12 with language delay and 10 with global developmental delay) were matched with the autism group based on chronological age, verbal and nonverbal developmental quotient as assessed on the Mullen Scales of Early Learning, and overall functioning.

Overall, the percentage of time that the toddlers spent viewing the geometric images was significantly different among the diagnostic groups. Toddlers with autism spectrum disorders fixated significantly longer on geometric images than did developmentally typical or developmentally delayed toddlers.

Forty percent of the autism group spent more than half their viewing time fixated on the geometric images, compared with only 2% of the developmentally typical toddlers and 9% of the developmentally delayed toddlers. Many of the children with autism spectrum disorders spent more than 70% of their viewing time watching the geometric images, and several spent more than 90% of their viewing time doing so—a percentage that was never found in either of the other groups.

When a cutoff was established at 69% of viewing time spent on geometric rather than social images, autism spectrum disorders were correctly predicted in 100% of the affected children and in none of the other groups of children.

The children with autism spectrum disorders who showed the most distinct preference for geometric images also showed a unique pattern of saccades, or abrupt eye movements, while viewing the movie. They showed significantly fewer saccades than did any of the other children when looking at their preferred geometric stimuli, and conversely they showed nearly twice as many saccades when looking at the social stimuli.

Other researchers have postulated that increased saccades while viewing faces reflects anxiety among people with autistic spectrum disorders, Dr. Pierce and her associates said (Arch. Gen. Psychiatry 2010 Sept. 6 [doi:10.1001/archgenpsychiatry2010.113]).

The findings show that a preference for watching geometric images plus aberrations in the number of saccades might indicate risk for an autism spectrum disorder in children as young as 14 months of age. In addition, "we believe that it may be easy to capture this preference using relatively inexpensive techniques in mainstream clinical settings such as a pediatrician’s office," they noted.

Infants and children found to follow these patterns of eye movement would be "excellent candidates for further developmental evaluation and possible early treatment."

However, it is important to note that 60% of the subjects with autism spectrum disorders did not exhibit these patterns, and that those who did were not necessarily the ones with the most pronounced symptoms.

Moreover, "while the discovery of a putative new early warning sign of autism is encouraging, results should be interpreted with some caution" because approximately 20% of the initial study population was excluded because of poor compliance with testing, the researchers added.

This study was funded by grants from the National Institute of Mental Health.

Toddlers at risk for autism spectrum disorders preferred to look at geometric patterns more than social images in a 1-minute experiment, in contrast to developmentally delayed and developmentally normal toddlers, according to a report published online Sept. 6 in the Archives of General Psychiatry.

"When the percentage of time a toddler spent fixating on geometric patterns was 69% or greater, the positive predictive validity for accurately classifying that toddler as having an autism spectrum disorder was 100%," said Karen Pierce, Ph.D., department of neurosciences, Autism Center of Excellence, University of California, San Diego, and her associates.

Other investigators have used eye-tracking technology to assess differences between autistic and other infants and young children in response to pictures of faces. However, "given the active pace of brain development during the infancy period combined with high intersubject variability of eye tracking patterns to faces during this time, examining the percentage of time an infant attends to the eye region of a face may not be stable enough to make diagnostically predictive claims," Dr. Pierce and her colleagues noted.

"An alternative method to investigate early indicators of autism is to measure a very simple behavior: preference."

Developmentally normal infants and toddlers are known to show a distinct preference for faces when presented with two different images to look at. "What infants prefer to look at when given a choice between two images may turn out to be a more clearly observable indicator of risk than how they look at a single image," the researchers said.

To test this hypothesis, they used eye-tracking technology to monitor subjects’ gaze when watching split-screen moving images of children dancing or performing yoga on one side (dynamic social images) and moving geometric shapes on the other (dynamic geometric images). This movie contained 28 separate scenes, with each scene varying in duration from 2 to 4 seconds, for a total presentation time of 1 minute.

The study subjects were 110 toddlers (aged 14-42 months). A total of 37 children had autism spectrum disorders (27 with autistic disorder, 9 with pervasive developmental delay not otherwise specified, and 1 with autism spectrum features). Another 51 children, matched for age and gender, were developmentally normal. And 22 children who had developmental delay (12 with language delay and 10 with global developmental delay) were matched with the autism group based on chronological age, verbal and nonverbal developmental quotient as assessed on the Mullen Scales of Early Learning, and overall functioning.

Overall, the percentage of time that the toddlers spent viewing the geometric images was significantly different among the diagnostic groups. Toddlers with autism spectrum disorders fixated significantly longer on geometric images than did developmentally typical or developmentally delayed toddlers.

Forty percent of the autism group spent more than half their viewing time fixated on the geometric images, compared with only 2% of the developmentally typical toddlers and 9% of the developmentally delayed toddlers. Many of the children with autism spectrum disorders spent more than 70% of their viewing time watching the geometric images, and several spent more than 90% of their viewing time doing so—a percentage that was never found in either of the other groups.

When a cutoff was established at 69% of viewing time spent on geometric rather than social images, autism spectrum disorders were correctly predicted in 100% of the affected children and in none of the other groups of children.

The children with autism spectrum disorders who showed the most distinct preference for geometric images also showed a unique pattern of saccades, or abrupt eye movements, while viewing the movie. They showed significantly fewer saccades than did any of the other children when looking at their preferred geometric stimuli, and conversely they showed nearly twice as many saccades when looking at the social stimuli.

Other researchers have postulated that increased saccades while viewing faces reflects anxiety among people with autistic spectrum disorders, Dr. Pierce and her associates said (Arch. Gen. Psychiatry 2010 Sept. 6 [doi:10.1001/archgenpsychiatry2010.113]).

The findings show that a preference for watching geometric images plus aberrations in the number of saccades might indicate risk for an autism spectrum disorder in children as young as 14 months of age. In addition, "we believe that it may be easy to capture this preference using relatively inexpensive techniques in mainstream clinical settings such as a pediatrician’s office," they noted.

Infants and children found to follow these patterns of eye movement would be "excellent candidates for further developmental evaluation and possible early treatment."

However, it is important to note that 60% of the subjects with autism spectrum disorders did not exhibit these patterns, and that those who did were not necessarily the ones with the most pronounced symptoms.

Moreover, "while the discovery of a putative new early warning sign of autism is encouraging, results should be interpreted with some caution" because approximately 20% of the initial study population was excluded because of poor compliance with testing, the researchers added.

This study was funded by grants from the National Institute of Mental Health.

Toddlers at risk for autism spectrum disorders preferred to look at geometric patterns more than social images in a 1-minute experiment, in contrast to developmentally delayed and developmentally normal toddlers, according to a report published online Sept. 6 in the Archives of General Psychiatry.

"When the percentage of time a toddler spent fixating on geometric patterns was 69% or greater, the positive predictive validity for accurately classifying that toddler as having an autism spectrum disorder was 100%," said Karen Pierce, Ph.D., department of neurosciences, Autism Center of Excellence, University of California, San Diego, and her associates.

Other investigators have used eye-tracking technology to assess differences between autistic and other infants and young children in response to pictures of faces. However, "given the active pace of brain development during the infancy period combined with high intersubject variability of eye tracking patterns to faces during this time, examining the percentage of time an infant attends to the eye region of a face may not be stable enough to make diagnostically predictive claims," Dr. Pierce and her colleagues noted.

"An alternative method to investigate early indicators of autism is to measure a very simple behavior: preference."

Developmentally normal infants and toddlers are known to show a distinct preference for faces when presented with two different images to look at. "What infants prefer to look at when given a choice between two images may turn out to be a more clearly observable indicator of risk than how they look at a single image," the researchers said.

To test this hypothesis, they used eye-tracking technology to monitor subjects’ gaze when watching split-screen moving images of children dancing or performing yoga on one side (dynamic social images) and moving geometric shapes on the other (dynamic geometric images). This movie contained 28 separate scenes, with each scene varying in duration from 2 to 4 seconds, for a total presentation time of 1 minute.

The study subjects were 110 toddlers (aged 14-42 months). A total of 37 children had autism spectrum disorders (27 with autistic disorder, 9 with pervasive developmental delay not otherwise specified, and 1 with autism spectrum features). Another 51 children, matched for age and gender, were developmentally normal. And 22 children who had developmental delay (12 with language delay and 10 with global developmental delay) were matched with the autism group based on chronological age, verbal and nonverbal developmental quotient as assessed on the Mullen Scales of Early Learning, and overall functioning.

Overall, the percentage of time that the toddlers spent viewing the geometric images was significantly different among the diagnostic groups. Toddlers with autism spectrum disorders fixated significantly longer on geometric images than did developmentally typical or developmentally delayed toddlers.

Forty percent of the autism group spent more than half their viewing time fixated on the geometric images, compared with only 2% of the developmentally typical toddlers and 9% of the developmentally delayed toddlers. Many of the children with autism spectrum disorders spent more than 70% of their viewing time watching the geometric images, and several spent more than 90% of their viewing time doing so—a percentage that was never found in either of the other groups.

When a cutoff was established at 69% of viewing time spent on geometric rather than social images, autism spectrum disorders were correctly predicted in 100% of the affected children and in none of the other groups of children.

The children with autism spectrum disorders who showed the most distinct preference for geometric images also showed a unique pattern of saccades, or abrupt eye movements, while viewing the movie. They showed significantly fewer saccades than did any of the other children when looking at their preferred geometric stimuli, and conversely they showed nearly twice as many saccades when looking at the social stimuli.

Other researchers have postulated that increased saccades while viewing faces reflects anxiety among people with autistic spectrum disorders, Dr. Pierce and her associates said (Arch. Gen. Psychiatry 2010 Sept. 6 [doi:10.1001/archgenpsychiatry2010.113]).

The findings show that a preference for watching geometric images plus aberrations in the number of saccades might indicate risk for an autism spectrum disorder in children as young as 14 months of age. In addition, "we believe that it may be easy to capture this preference using relatively inexpensive techniques in mainstream clinical settings such as a pediatrician’s office," they noted.

Infants and children found to follow these patterns of eye movement would be "excellent candidates for further developmental evaluation and possible early treatment."

However, it is important to note that 60% of the subjects with autism spectrum disorders did not exhibit these patterns, and that those who did were not necessarily the ones with the most pronounced symptoms.

Moreover, "while the discovery of a putative new early warning sign of autism is encouraging, results should be interpreted with some caution" because approximately 20% of the initial study population was excluded because of poor compliance with testing, the researchers added.

This study was funded by grants from the National Institute of Mental Health.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

A primary care–based intervention significantly improved glycated hemoglobin, LDL cholesterol, blood pressure, and depression outcomes in patients who had concomitant coronary heart disease, diabetes, and depression, according to a randomized, controlled trial reported online Dec. 30 in the New England Journal of Medicine

The intervention also improved quality of life and patient satisfaction with their health care, said Dr. Wayne J. Katon of the departments of psychiatry and behavioral sciences, University of Washington, Seattle, and his associates.

The investigators designed the intervention in part because "the care of patients with multiple chronic diseases accounts for the majority of health care costs, [and] effective approaches to managing such complex care in primary [practice] are needed, particularly when psychological and physical disorders coexist."

The intervention targeted patients with major depression and poorly controlled diabetes, coronary heart disease (CHD), or both. It included structured patient visits every 2-3 weeks to 14 clinics comprising 151 primary care physicians. In each clinic, three part-time nurses promoted patient self-care, provided educational materials, and monitored control of depression, hyperglycemia, hypertension, and hyperlipidemia. The nurses received weekly supervision with a psychiatrist, a primary care physician, and a psychologist to review patient progress and adjust treatment as necessary. The estimated cost of the intervention was $1,224 per patient.

To assess the effectiveness of the intervention, Dr. Katon and his colleagues randomly assigned 106 patients to receive the intervention and 108 to receive usual care for 1 year.

At the conclusion of the study, patients in the intervention group showed significantly greater overall improvement than did controls in hemoglobin A1c (mean decrease 0.58%), LDL cholesterol (a mean decrease of 6.9 mg/dL), and systolic blood pressure (mean decrease 5.1 mm Hg), as well as significantly improved scores on the SCL-20 measure of depression (mean decrease 0.40 points). These differences are greater than those reported in the literature for trials of single CHD and diabetes medications, the investigators noted.

A higher proportion of patients in the intervention group (37%) than in the control group (22%) attained values on all three medical risk factors that met levels recommended in clinical guidelines, and a higher proportion also showed reductions of 50% or more in SCL-20 scores.

The study was not adequately powered to detect between-group differences in rates of hospitalization or cardiovascular events. "Although effects on the glycated hemoglobin level, LDL cholesterol level, and systolic blood pressure were modest, on a population level they may meaningfully decrease the risks of macrovascular and microvascular disease," Dr. Katon and his associates said (N. Engl. J. Med. 2010;363:2611-20).

Patients in the intervention group also were significantly more likely than were those in the control group to have made changes in their doses of insulin, antihypertensive drugs, and antidepressants during the study period.

In self-reports, patients in the intervention group showed greater improvements in quality of life and said they were more satisfied with their health care than did patients in the usual-care group.

"Our results suggest that an intervention involving coordinated efforts of physicians and nurses may facilitate the care of patients with multiple conditions within a primary care medical home," the researchers said.

This study was supported by the National Institute of Mental Health and the Group Health Cooperative. Dr. Katon and his associates reported ties to Wyeth, Eli Lilly, Forest, Pfizer, Prescott Medical, HealthSTAR Communications, the World Psychiatry Association, John A. Hartford Foundation, Johnson & Johnson, Samepage, and Roche Diagnostics.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

The increased risk of death linked to childhood-onset epilepsy appears to be substantial, and it persists into adulthood, according to a report in the Dec. 23 issue of the New England Journal of Medicine.

In a cohort of 245 Finnish patients diagnosed as having epilepsy in the early 1960s and followed until 2002, overall mortality was 24% – three times higher than would be expected in the general population of the same age, said Dr. Mattii Sillanpaa of the departments of pediatrics and neurology at the University of Turku, Finland, and his associates.

"Few studies have evaluated long-term mortality in well-characterized cohorts of children with epilepsy," and most of those have been retrospective and have not included autopsy confirmation of other causes of death. Dr. Sillanpaa and his colleagues assessed mortality in a group of patients evaluated between 1961 and 1964 at a median age of 3 years who were then followed prospectively for a median of 40 years; 70% of the study subjects who died underwent autopsy.

A total of 122 patients had idiopathic or cryptogenic epilepsy and 123 had "remote symptomatic epilepsy" associated with a major neurologic abnormality or insult. At final follow-up or death, 110 patients (45%) were in 5-year terminal remission and were not receiving any medication, 28 (11%) were in 5-year terminal remission and were receiving medication, and 107 (44%) were not in 5-year remission.

A total of 60 patients died, for an overall mortality of 24% and a rate of death of 6.9 per 1,000 person-years.

Death was directly related to epilepsy in 33 patients (55% of those who died), and was not related to epilepsy but to an underlying neurologic problem or another disease in the remaining 26 patients (45% of those who died). In one patient, the cause of death was unknown. The former group included 18 patients with "sudden, unexplained death in epilepsy," 9 with definite or probable seizure, and 6 with accidental drowning.

"With the use of the alternative classification of sudden, unexplained death in epilepsy, which includes possible or definite seizures as long as the seizures were not status epilepticus, 38% of the deaths were due to sudden, unexplained death in epilepsy, 7% were due to status epilepticus, and 10% were due to accidental drowning," they said.

Sudden, unexplained death occurred in 9% of the overall cohort, at a median age of 25 years. The cumulative risk of sudden, unexplained death was 7% at 40 years.

As expected, mortality was significantly higher in patients who had remote symptomatic epilepsy (11.1 deaths per 1,000 person-years) than in those with cryptogenic epilepsy (2.9 per 1,000 person-years) or idiopathic epilepsy (3.5 per 1,000 person-years).

"More than three-quarters of the deaths occurred in subjects who were not in 5-year terminal remission and in the groups with epilepsy due to remote symptomatic causes: these included 21 of the 26 deaths not directly related to epilepsy and 24 of the 33 deaths related to epilepsy," the investigators said (N. Engl. J. Med. 2010;363:2522-9).

"Our data alone do not provide support for aggressive treatment to prevent sudden, unexplained death in patients with epilepsy. However, studies of epilepsy surgery in adults with medically refractory partial epilepsy have shown that the rates of sudden, unexplained death are substantially lower among those who become seizure free after surgery than among those who do not, suggesting that the risk is potentially modifiable," they added.

This study was supported by a grant from the Finnish Epilepsy Research Foundation. No financial disclosures were reported.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20 in the Archives of Dermatology.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and CRP levels. "Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis," reported Dr. Thorvardur Jon Love of Brigham and Women’s Hospital, Boston, and his associates.

"Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis," they noted.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients. In particular, patients with severe psoriasis have been reported to be at an increased risk for MI, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis. The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When CRP levels were removed from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 Dec. 20 [doi:10.1001/archdermatol.2010.370]).

"When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% CI, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis," they noted.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that "a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications," Dr. Love and his colleagues wrote.

This association also should be considered when choosing therapy for psoriasis. "For example, tumor necrosis factor blockers may decrease insulin resistance," they added.

This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20 in the Archives of Dermatology.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and CRP levels. "Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis," reported Dr. Thorvardur Jon Love of Brigham and Women’s Hospital, Boston, and his associates.

"Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis," they noted.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients. In particular, patients with severe psoriasis have been reported to be at an increased risk for MI, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis. The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When CRP levels were removed from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 Dec. 20 [doi:10.1001/archdermatol.2010.370]).

"When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% CI, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis," they noted.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that "a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications," Dr. Love and his colleagues wrote.

This association also should be considered when choosing therapy for psoriasis. "For example, tumor necrosis factor blockers may decrease insulin resistance," they added.

This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.

Forty percent of patients with psoriasis were found to have the metabolic syndrome in a study of a nationally representative sample of more than 6,500 adults published online Dec. 20 in the Archives of Dermatology.

The prevalence of the metabolic syndrome was approximately twice as high in psoriasis patients as in adults without psoriasis, even after adjustment for potential confounders such as age, sex, race/ethnicity, smoking status, and CRP levels. "Given its associated serious complications, this comorbidity needs to be recognized and taken into account when treating individuals with psoriasis," reported Dr. Thorvardur Jon Love of Brigham and Women’s Hospital, Boston, and his associates.

"Based on these data, it is estimated that of the 6.6 million adults (age range 20-59 years) with psoriasis in the United States, 2.7 million have the metabolic syndrome, or nearly a million more individuals than would be expected from individuals without psoriasis," they noted.

The study findings may partially explain why previous research has found increased risks of cardiovascular and metabolic morbidity and mortality among psoriasis patients. In particular, patients with severe psoriasis have been reported to be at an increased risk for MI, stroke, and cardiovascular mortality, and have been reported to die 3-4 years earlier than people without psoriasis, the investigators added.

The metabolic syndrome is characterized by abdominal obesity, hypertriglyceridemia, low HDL cholesterol levels, hypertension, and high fasting glucose levels. Recent research has pegged the incidence of the disorder at 15%-24% in the general U.S. population.

Noting that there has been only one previous study examining the relationship between psoriasis and the metabolic syndrome, and that until now there have been no population-based data on the issue, Dr. Love and his colleagues used data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006 to assess the prevalence of the metabolic syndrome and its components in psoriasis.

The study subjects included 2,456 adults (mean age 39 years) who did not have preexisting diabetes; 71 had psoriasis.

The prevalence of the metabolic syndrome was 40% among psoriasis patients, compared with 23% among patients without psoriasis. The odds ratio for patients with psoriasis to have the metabolic syndrome was 2.16 on univariate analysis and 1.96 after the data were adjusted to account for potential confounding factors.

When CRP levels were removed from the analysis to cancel out the potentially confounding effect of inflammation, odds ratios did not change materially, Dr. Love and his associates reported (Arch. Dermatol. 2010 Dec. 20 [doi:10.1001/archdermatol.2010.370]).

"When we applied these data to the 2008 U.S. census population estimate, 6.6 million (95% CI, 4.8-8.3) individuals aged 20-59 years were estimated to have psoriasis in the United States, and 2.7 million (95% CI, 1.6-3.6) of these individuals with psoriasis were estimated to have the metabolic syndrome, an excess of 1 million patients compared with the expected value among individuals without psoriasis," they noted.

The most common feature of the metabolic syndrome to be found among psoriasis patients was abdominal obesity, present in 63%. Hypertriglyceridemia and low HDL-cholesterol levels also were common.

These findings indicate that "a diagnosis of psoriasis should trigger a high clinical suspicion [of] and investigation for a potential coexistence of the metabolic syndrome. If present, the syndrome needs to be recognized as a potentially more life-threatening factor than psoriasis given the serious associated complications," Dr. Love and his colleagues wrote.

This association also should be considered when choosing therapy for psoriasis. "For example, tumor necrosis factor blockers may decrease insulin resistance," they added.

This study was supported in part by the National Institutes of Health, the Psoriasis Foundation, and the National Heart, Lung, and Blood Institute. One of Dr. Love's associates reported ties to Amgen, Abbott, Celgene, Centocor, Pfizer, and Novartis.