Michele G. Sullivan

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group—a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.

'A lot of kids and their parents are not psycho-logically ready for daily injections at this age.' DR. KAPLOWITZ

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group—a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.

'A lot of kids and their parents are not psycho-logically ready for daily injections at this age.' DR. KAPLOWITZ

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group—a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.

'A lot of kids and their parents are not psycho-logically ready for daily injections at this age.' DR. KAPLOWITZ

Mycobacterium tuberculosis infection is becoming increasingly common among children adopted from foreign countries, Dr. Anna Mandalakas and her colleagues reported.

Because of this risk, international adoptees should receive tuberculin screening as soon as possible after their arrival in their new country, wrote Dr. Mandalakas of Case Western Reserve University, Cleveland, Ohio, and her coauthors (Pediatrics 2007;120:610-6).

“In addition, because of the risk of a false-negative [screen] after recent exposure to M. tuberculosis or secondary to malnutrition, clinicians should consider repeating the screen 3–6 months after children arrive in their adoptive countries and when nutrition has improved,” they said.

The team performed a retrospective review of 869 adoptees (mean age 26 months) who presented to the International Adoption Clinic at the University of Minnesota, Minneapolis, from 1986 to 2001. In addition to receiving a tuberculin skin test, each child underwent a nutritional assessment that included measurements of weight, height, length, and body mass index.

Twenty-eight percent of the group had evidence of chronic malnutrition, and 5% had evidence of acute malnutrition.

Based on a previously published analysis of a subset of this group, the investigators expected to find M. tuberculosis infection in about 12 (1%) of the 869 children. The rate of infection was much higher, with 12% of the group (102) showing a tuberculin skin test (TST) induration of at least 10 mm.

The frequency of a positive skin test did not differ among birth countries nor was it related to the presence of malnutrition. However, the proportion of children with a positive skin test increased over the study period. When the investigators controlled for the effect of age, the odds of having an infection increased 7% for each year during the study period.

The risk also increased 142% for each additional year of age for children who were younger than 24 months at the time of screening, and 15% with each additional year of age for children older than 24 months at the time of screening. This linear age-adjusted risk was present in all birth regions, the authors wrote. “Although this increase mirrors global trends during the same period, the degree of increase is substantially greater and highlights the need to identify factors within the orphanage that contribute to these children's risk for infection.”

The significantly increased risk among younger children probably reflects their close contact with infected caregivers. Most of the adoptees came from orphanages in which they were age segregated, so it's unlikely that they contracted the infection from older children or community members, they wrote.

“Our data suggest that a significant portion of children who live in orphanages are exposed to infectious adults with active tuberculosis. In children with exposure to an infectious adult, the TST should be interpreted as positive when TST indurations are greater than or equal to 5 mm. Therefore, our study likely underestimates the number of children who would receive a diagnosis of M. tuberculosis infection if the history regarding tuberculosis exposure were available. In addition, children with recently acquired M. tuberculosis infection may not have fully developed their immune response and associated TST response,” the investigators said.

They suggested that that added screening such as chest x-ray and a repeat TST 3–6 months after arrival may be a good idea in internationally adopted children with TST indurations greater than or equal to 5 mm.

“Although our study did not demonstrate a statistically significant association between nutritional status and TST reactivity, this lack of association reflects the small number of children defined as severely malnourished in our study and the resultant limitations in power to complete nutritionally stratified analysis,” Dr. Mandalakas and her associates said. Previous studies have shown that malnourished children—especially severely malnourished ones—who have an associated impairment in T-cell function may not be responsive to the TST.

Mycobacterium tuberculosis infection is becoming increasingly common among children adopted from foreign countries, Dr. Anna Mandalakas and her colleagues reported.

Because of this risk, international adoptees should receive tuberculin screening as soon as possible after their arrival in their new country, wrote Dr. Mandalakas of Case Western Reserve University, Cleveland, Ohio, and her coauthors (Pediatrics 2007;120:610-6).

“In addition, because of the risk of a false-negative [screen] after recent exposure to M. tuberculosis or secondary to malnutrition, clinicians should consider repeating the screen 3–6 months after children arrive in their adoptive countries and when nutrition has improved,” they said.

The team performed a retrospective review of 869 adoptees (mean age 26 months) who presented to the International Adoption Clinic at the University of Minnesota, Minneapolis, from 1986 to 2001. In addition to receiving a tuberculin skin test, each child underwent a nutritional assessment that included measurements of weight, height, length, and body mass index.

Twenty-eight percent of the group had evidence of chronic malnutrition, and 5% had evidence of acute malnutrition.

Based on a previously published analysis of a subset of this group, the investigators expected to find M. tuberculosis infection in about 12 (1%) of the 869 children. The rate of infection was much higher, with 12% of the group (102) showing a tuberculin skin test (TST) induration of at least 10 mm.

The frequency of a positive skin test did not differ among birth countries nor was it related to the presence of malnutrition. However, the proportion of children with a positive skin test increased over the study period. When the investigators controlled for the effect of age, the odds of having an infection increased 7% for each year during the study period.

The risk also increased 142% for each additional year of age for children who were younger than 24 months at the time of screening, and 15% with each additional year of age for children older than 24 months at the time of screening. This linear age-adjusted risk was present in all birth regions, the authors wrote. “Although this increase mirrors global trends during the same period, the degree of increase is substantially greater and highlights the need to identify factors within the orphanage that contribute to these children's risk for infection.”

The significantly increased risk among younger children probably reflects their close contact with infected caregivers. Most of the adoptees came from orphanages in which they were age segregated, so it's unlikely that they contracted the infection from older children or community members, they wrote.

“Our data suggest that a significant portion of children who live in orphanages are exposed to infectious adults with active tuberculosis. In children with exposure to an infectious adult, the TST should be interpreted as positive when TST indurations are greater than or equal to 5 mm. Therefore, our study likely underestimates the number of children who would receive a diagnosis of M. tuberculosis infection if the history regarding tuberculosis exposure were available. In addition, children with recently acquired M. tuberculosis infection may not have fully developed their immune response and associated TST response,” the investigators said.

They suggested that that added screening such as chest x-ray and a repeat TST 3–6 months after arrival may be a good idea in internationally adopted children with TST indurations greater than or equal to 5 mm.

“Although our study did not demonstrate a statistically significant association between nutritional status and TST reactivity, this lack of association reflects the small number of children defined as severely malnourished in our study and the resultant limitations in power to complete nutritionally stratified analysis,” Dr. Mandalakas and her associates said. Previous studies have shown that malnourished children—especially severely malnourished ones—who have an associated impairment in T-cell function may not be responsive to the TST.

Mycobacterium tuberculosis infection is becoming increasingly common among children adopted from foreign countries, Dr. Anna Mandalakas and her colleagues reported.

Because of this risk, international adoptees should receive tuberculin screening as soon as possible after their arrival in their new country, wrote Dr. Mandalakas of Case Western Reserve University, Cleveland, Ohio, and her coauthors (Pediatrics 2007;120:610-6).

“In addition, because of the risk of a false-negative [screen] after recent exposure to M. tuberculosis or secondary to malnutrition, clinicians should consider repeating the screen 3–6 months after children arrive in their adoptive countries and when nutrition has improved,” they said.

The team performed a retrospective review of 869 adoptees (mean age 26 months) who presented to the International Adoption Clinic at the University of Minnesota, Minneapolis, from 1986 to 2001. In addition to receiving a tuberculin skin test, each child underwent a nutritional assessment that included measurements of weight, height, length, and body mass index.

Twenty-eight percent of the group had evidence of chronic malnutrition, and 5% had evidence of acute malnutrition.

Based on a previously published analysis of a subset of this group, the investigators expected to find M. tuberculosis infection in about 12 (1%) of the 869 children. The rate of infection was much higher, with 12% of the group (102) showing a tuberculin skin test (TST) induration of at least 10 mm.

The frequency of a positive skin test did not differ among birth countries nor was it related to the presence of malnutrition. However, the proportion of children with a positive skin test increased over the study period. When the investigators controlled for the effect of age, the odds of having an infection increased 7% for each year during the study period.

The risk also increased 142% for each additional year of age for children who were younger than 24 months at the time of screening, and 15% with each additional year of age for children older than 24 months at the time of screening. This linear age-adjusted risk was present in all birth regions, the authors wrote. “Although this increase mirrors global trends during the same period, the degree of increase is substantially greater and highlights the need to identify factors within the orphanage that contribute to these children's risk for infection.”

The significantly increased risk among younger children probably reflects their close contact with infected caregivers. Most of the adoptees came from orphanages in which they were age segregated, so it's unlikely that they contracted the infection from older children or community members, they wrote.

“Our data suggest that a significant portion of children who live in orphanages are exposed to infectious adults with active tuberculosis. In children with exposure to an infectious adult, the TST should be interpreted as positive when TST indurations are greater than or equal to 5 mm. Therefore, our study likely underestimates the number of children who would receive a diagnosis of M. tuberculosis infection if the history regarding tuberculosis exposure were available. In addition, children with recently acquired M. tuberculosis infection may not have fully developed their immune response and associated TST response,” the investigators said.

They suggested that that added screening such as chest x-ray and a repeat TST 3–6 months after arrival may be a good idea in internationally adopted children with TST indurations greater than or equal to 5 mm.

“Although our study did not demonstrate a statistically significant association between nutritional status and TST reactivity, this lack of association reflects the small number of children defined as severely malnourished in our study and the resultant limitations in power to complete nutritionally stratified analysis,” Dr. Mandalakas and her associates said. Previous studies have shown that malnourished children—especially severely malnourished ones—who have an associated impairment in T-cell function may not be responsive to the TST.

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group, a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington, D.C. “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.”

Waiting until 9 years or older to start growth hormone injections “clearly is not optimal,” Dr. Kaplowitz said. “But the study does not prove that results of starting at 2–4 years old are much better than starting at 5–6 years old.”

Parents shouldn't feel pressured to start treatment until the child is falling considerably behind on her growth curve, he added.

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group, a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington, D.C. “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.”

Waiting until 9 years or older to start growth hormone injections “clearly is not optimal,” Dr. Kaplowitz said. “But the study does not prove that results of starting at 2–4 years old are much better than starting at 5–6 years old.”

Parents shouldn't feel pressured to start treatment until the child is falling considerably behind on her growth curve, he added.

Early treatment with growth hormone can correct growth failure in infants and toddlers with Turner syndrome, allowing many of them to achieve normal height within a few years, Dr. Marsha Davenport and her colleagues reported.

In their randomized placebo-controlled trial, 93% of the girls who received growth hormone achieved a height within normal range before they were 6 years old. The success rate is probably related to early intervention, reported Dr. Davenport, of the University of North Carolina at Chapel Hill, and her associates. “In general, the younger the patient is at growth hormone initiation, the smaller the height deficit to be bridged and the faster height is normalized” (J. Clin. Endocrinol. Metab. 2007;92:3406–16).

Dr. Paul Kaplowitz, a member of the American Academy of Pediatrics section on endocrinology, expressed some concern about the difficulty of daily injections for such young children.

The investigators randomized 88 girls (mean age 2 years; range 9 months to 4 years) to either no intervention or to 2 years of daily injections with recombinant growth hormone (50 mcg/kg).

At baseline, the mean length/height standard deviation score (SDS) was −1.6. Chronologic age and bone age were not significantly different in any of the girls. Fifty-six had a 45,X karyotype; 14 had a 45,X/46,XX karyotype; and 18 had a variety of other karyotypes.

Compliance with growth hormone treatment was very good, with patients receiving an average of 95% of their scheduled injections.

Treatment corrected growth failure and promoted catch-up growth. In the treatment group, height increased from a baseline SDS of −1.4 to −0.3 at year 2. The control group continued to experience growth failure, falling from a height SDS of −1.8 at baseline to −2.2 by the second year.

During the 2-year study, girls who took growth hormone grew an average of 20.4 cm, compared with an average 13.6 cm in the control group, a significant difference.

The effect of growth hormone was rapid, the investigators noted; by 4 months, the height difference between the groups became significant. In the first year, girls taking growth hormone grew significantly more than those in the control group (11.7 cm vs. 8 cm). The difference was smaller, but still significant, in the second year of treatment (8.4 cm vs. 5.5 cm).

Bone age and chronologic age were similar in both groups at baseline, but by the end of the study, girls in the growth hormone group experienced a small advance in bone age, compared with chronologic age, whereas bone age had fallen behind in the control group.

Karyotype did not significantly affect response to growth hormone. There were no significant safety concerns; none of the adverse events were deemed related to the study medication.

There are probably few, if any, safety issues with giving growth hormone to girls of this age, Dr. Kaplowitz commented in an interview. Instead, he expressed some trepidation about problems giving daily injections to such young children.

“I would not be concerned about safety since there is ample data on that for older girls and there is no reason to think younger girls would be different,” said Dr. Kaplowitz, chief of endocrinology at the Children's National Medical Center, Washington, D.C. “The results show clearly that [growth hormone] is safe and effective for girls with Turner syndrome who are between 9 months and 4 years old. My concern is that a lot of kids and their parents are not psychologically ready for daily injections at this age.”

Some girls with Turner syndrome display anxiety and agitation that makes even routine office exams difficult for the physician and traumatic for the child. “I would not want those parents to have to fight with these girls to give them daily injections until they are considerably older and more cooperative.”

Waiting until 9 years or older to start growth hormone injections “clearly is not optimal,” Dr. Kaplowitz said. “But the study does not prove that results of starting at 2–4 years old are much better than starting at 5–6 years old.”

Parents shouldn't feel pressured to start treatment until the child is falling considerably behind on her growth curve, he added.

CHICAGO – Migraine appears to have a favorable long-term prognosis in many patients, with more than a third experiencing cessation of headache and the vast majority of persistent migraineurs reporting symptom improvement over 12 years.

“These data probably reflect the natural course of migraine disease,” Dr. Carl Dahlöf said at the annual meeting of the American Headache Society. “They also probably suggest that we are doing a better job with the newer drugs, and appear to be preventing episodic migraineurs from developing chronic migraine.”

Dr. Dahlöf of the Göteborg (Sweden) Migraine Clinic presented 12 years of follow-up data obtained on 374 patients diagnosed with migraine before 1996. The group included 200 men and 174 women, a ratio that does not reflect the gender balance seen in any headache practice, Dr. Dahlöf noted. “We chose equal numbers of men and women because we wanted to see if there were any gender differences in progression or improvement over the years.”

All patients participated in a telephone survey that assessed the changing pattern of their migraine from 1994 to 2006.

Over the follow-up period, 29% of patients (57 women and 53 men) reported that their migraines had ceased. For women, migraine without aura, the absence of hereditary factors, and the absence of aggravation from physical activity appeared to predict cessation. For men, the apparent predictors were a nonthrobbing migraine, and the absence of nausea and sensitivity to smells.

“Surprisingly, we also found in men that smoking and lack of alcohol as a trigger factor were also predictors,” Dr. Dahlöf said. “We had expected that more frequent or severe migraine would predict progression, but we did not find this as true.”

The remaining 264 patients continued to experience migraine, but the majority reported at least some improvement of their symptoms over time.

In all, 80% reported a change in headache frequency, with 80% of these saying they had fewer attacks per month.

More than half of persistent migraineurs reported a change in duration of headache, with 66% saying their attacks had grown shorter. In terms of severity, 66% of migraineurs reported a change in pain intensity over time, with most of this group (84%) reporting milder pain.

Of the entire group of 374 patients, only six (1.6%) developed chronic migraine, a number that is vastly smaller than the annual transformation rate reported in many studies, Dr. Dahlöf said.

Despite the changing pattern of migraine, a significant proportion of migraineurs continued to experience impairment in their quality of life, including decreased family and social functioning, and absence from work.

CHICAGO – Migraine appears to have a favorable long-term prognosis in many patients, with more than a third experiencing cessation of headache and the vast majority of persistent migraineurs reporting symptom improvement over 12 years.

“These data probably reflect the natural course of migraine disease,” Dr. Carl Dahlöf said at the annual meeting of the American Headache Society. “They also probably suggest that we are doing a better job with the newer drugs, and appear to be preventing episodic migraineurs from developing chronic migraine.”

Dr. Dahlöf of the Göteborg (Sweden) Migraine Clinic presented 12 years of follow-up data obtained on 374 patients diagnosed with migraine before 1996. The group included 200 men and 174 women, a ratio that does not reflect the gender balance seen in any headache practice, Dr. Dahlöf noted. “We chose equal numbers of men and women because we wanted to see if there were any gender differences in progression or improvement over the years.”

All patients participated in a telephone survey that assessed the changing pattern of their migraine from 1994 to 2006.

Over the follow-up period, 29% of patients (57 women and 53 men) reported that their migraines had ceased. For women, migraine without aura, the absence of hereditary factors, and the absence of aggravation from physical activity appeared to predict cessation. For men, the apparent predictors were a nonthrobbing migraine, and the absence of nausea and sensitivity to smells.

“Surprisingly, we also found in men that smoking and lack of alcohol as a trigger factor were also predictors,” Dr. Dahlöf said. “We had expected that more frequent or severe migraine would predict progression, but we did not find this as true.”

The remaining 264 patients continued to experience migraine, but the majority reported at least some improvement of their symptoms over time.

In all, 80% reported a change in headache frequency, with 80% of these saying they had fewer attacks per month.

More than half of persistent migraineurs reported a change in duration of headache, with 66% saying their attacks had grown shorter. In terms of severity, 66% of migraineurs reported a change in pain intensity over time, with most of this group (84%) reporting milder pain.

Of the entire group of 374 patients, only six (1.6%) developed chronic migraine, a number that is vastly smaller than the annual transformation rate reported in many studies, Dr. Dahlöf said.

Despite the changing pattern of migraine, a significant proportion of migraineurs continued to experience impairment in their quality of life, including decreased family and social functioning, and absence from work.

CHICAGO – Migraine appears to have a favorable long-term prognosis in many patients, with more than a third experiencing cessation of headache and the vast majority of persistent migraineurs reporting symptom improvement over 12 years.

“These data probably reflect the natural course of migraine disease,” Dr. Carl Dahlöf said at the annual meeting of the American Headache Society. “They also probably suggest that we are doing a better job with the newer drugs, and appear to be preventing episodic migraineurs from developing chronic migraine.”

Dr. Dahlöf of the Göteborg (Sweden) Migraine Clinic presented 12 years of follow-up data obtained on 374 patients diagnosed with migraine before 1996. The group included 200 men and 174 women, a ratio that does not reflect the gender balance seen in any headache practice, Dr. Dahlöf noted. “We chose equal numbers of men and women because we wanted to see if there were any gender differences in progression or improvement over the years.”

All patients participated in a telephone survey that assessed the changing pattern of their migraine from 1994 to 2006.

Over the follow-up period, 29% of patients (57 women and 53 men) reported that their migraines had ceased. For women, migraine without aura, the absence of hereditary factors, and the absence of aggravation from physical activity appeared to predict cessation. For men, the apparent predictors were a nonthrobbing migraine, and the absence of nausea and sensitivity to smells.

“Surprisingly, we also found in men that smoking and lack of alcohol as a trigger factor were also predictors,” Dr. Dahlöf said. “We had expected that more frequent or severe migraine would predict progression, but we did not find this as true.”

The remaining 264 patients continued to experience migraine, but the majority reported at least some improvement of their symptoms over time.

In all, 80% reported a change in headache frequency, with 80% of these saying they had fewer attacks per month.

More than half of persistent migraineurs reported a change in duration of headache, with 66% saying their attacks had grown shorter. In terms of severity, 66% of migraineurs reported a change in pain intensity over time, with most of this group (84%) reporting milder pain.

Of the entire group of 374 patients, only six (1.6%) developed chronic migraine, a number that is vastly smaller than the annual transformation rate reported in many studies, Dr. Dahlöf said.

Despite the changing pattern of migraine, a significant proportion of migraineurs continued to experience impairment in their quality of life, including decreased family and social functioning, and absence from work.

Alzheimer disease advocates are calling for stepped-up measures to combat what is being called a “looming avalanche” of Alzheimer disease diagnoses in the United States.

Alzheimer disease prevalence in this country is projected to skyrocket in the next 40 years, tripling from 4.5 million now to more than 13 million. The national health infrastructure is simply not equipped to handle the increase, said Robert Egge of the Center for Health Transformation.

“The projections, not only in terms of the impact on individual lives, but also in national costs, are stunning,” Mr. Egge said in an interview. “Because of our national strategy—or rather the lack of it—we are not on the right footing to get a handle on this before it hits.”

The Center for Health Transformation, a health policy think-tank founded by former Speaker of the House Newt Gingrich, advocates the development of a national AD strategic plan

Such a plan would address two facets of the problem: money and leadership, said Mr. Egge, director of the center's Alzheimer disease project.

The numbers are distressing, he and Mr. Gingrich pointed out in a recently published commentary. AD is the nation's third most expensive medical condition, consuming $100 billion each year in Medicare and Medicaid dollars.

“Without medical breakthroughs, as the Boomers pass through their elder years, federal spending on AD care will increase to more than $1 trillion per year by 2050, in today's dollars. That is more than 10% of America's current gross domestic product,” they wrote (Alzheimers Dement. 2007;3:239–42).

A national AD strategy would build the case for making substantial national investments in research for both early detection and pharmacotherapy, and urge the Food and Drug Administration to accelerate new drug evaluation, Mr. Gingrich and Mr. Egge wrote. A strategic plan also should help caregivers, perhaps by providing some kind of financial support to those who save Medicare money by keeping a patient at home as long as possible.

The Alzheimer's Association has joined the Center for Health Transformation in taking the first steps toward building a national plan. In mid-July, the two entities announced the formation of a study group cochaired by Mr. Gingrich and former Sen. Bob Kerrey (D-Neb.). The group will consist of nonpartisan, independent health policy experts and is charged with evaluating the nation's efforts to combat the disease and recommend strategies for addressing shortcomings.

Alzheimer disease advocates are calling for stepped-up measures to combat what is being called a “looming avalanche” of Alzheimer disease diagnoses in the United States.

Alzheimer disease prevalence in this country is projected to skyrocket in the next 40 years, tripling from 4.5 million now to more than 13 million. The national health infrastructure is simply not equipped to handle the increase, said Robert Egge of the Center for Health Transformation.

“The projections, not only in terms of the impact on individual lives, but also in national costs, are stunning,” Mr. Egge said in an interview. “Because of our national strategy—or rather the lack of it—we are not on the right footing to get a handle on this before it hits.”

The Center for Health Transformation, a health policy think-tank founded by former Speaker of the House Newt Gingrich, advocates the development of a national AD strategic plan

Such a plan would address two facets of the problem: money and leadership, said Mr. Egge, director of the center's Alzheimer disease project.

The numbers are distressing, he and Mr. Gingrich pointed out in a recently published commentary. AD is the nation's third most expensive medical condition, consuming $100 billion each year in Medicare and Medicaid dollars.

“Without medical breakthroughs, as the Boomers pass through their elder years, federal spending on AD care will increase to more than $1 trillion per year by 2050, in today's dollars. That is more than 10% of America's current gross domestic product,” they wrote (Alzheimers Dement. 2007;3:239–42).

A national AD strategy would build the case for making substantial national investments in research for both early detection and pharmacotherapy, and urge the Food and Drug Administration to accelerate new drug evaluation, Mr. Gingrich and Mr. Egge wrote. A strategic plan also should help caregivers, perhaps by providing some kind of financial support to those who save Medicare money by keeping a patient at home as long as possible.

The Alzheimer's Association has joined the Center for Health Transformation in taking the first steps toward building a national plan. In mid-July, the two entities announced the formation of a study group cochaired by Mr. Gingrich and former Sen. Bob Kerrey (D-Neb.). The group will consist of nonpartisan, independent health policy experts and is charged with evaluating the nation's efforts to combat the disease and recommend strategies for addressing shortcomings.

Alzheimer disease advocates are calling for stepped-up measures to combat what is being called a “looming avalanche” of Alzheimer disease diagnoses in the United States.

Alzheimer disease prevalence in this country is projected to skyrocket in the next 40 years, tripling from 4.5 million now to more than 13 million. The national health infrastructure is simply not equipped to handle the increase, said Robert Egge of the Center for Health Transformation.

“The projections, not only in terms of the impact on individual lives, but also in national costs, are stunning,” Mr. Egge said in an interview. “Because of our national strategy—or rather the lack of it—we are not on the right footing to get a handle on this before it hits.”

The Center for Health Transformation, a health policy think-tank founded by former Speaker of the House Newt Gingrich, advocates the development of a national AD strategic plan

Such a plan would address two facets of the problem: money and leadership, said Mr. Egge, director of the center's Alzheimer disease project.

The numbers are distressing, he and Mr. Gingrich pointed out in a recently published commentary. AD is the nation's third most expensive medical condition, consuming $100 billion each year in Medicare and Medicaid dollars.

“Without medical breakthroughs, as the Boomers pass through their elder years, federal spending on AD care will increase to more than $1 trillion per year by 2050, in today's dollars. That is more than 10% of America's current gross domestic product,” they wrote (Alzheimers Dement. 2007;3:239–42).

A national AD strategy would build the case for making substantial national investments in research for both early detection and pharmacotherapy, and urge the Food and Drug Administration to accelerate new drug evaluation, Mr. Gingrich and Mr. Egge wrote. A strategic plan also should help caregivers, perhaps by providing some kind of financial support to those who save Medicare money by keeping a patient at home as long as possible.

The Alzheimer's Association has joined the Center for Health Transformation in taking the first steps toward building a national plan. In mid-July, the two entities announced the formation of a study group cochaired by Mr. Gingrich and former Sen. Bob Kerrey (D-Neb.). The group will consist of nonpartisan, independent health policy experts and is charged with evaluating the nation's efforts to combat the disease and recommend strategies for addressing shortcomings.

Elevated procalcitonin and C-reactive protein are highly predictive of a severe bacterial infection in infants and young children admitted to the emergency department with fever without a source, investigators reported.

With their optimal cutoff points, procalcitonin (PCT) and C-reactive protein (CRP) had both better sensitivity and specificity for severe bacterial infections than either white blood cell or absolute neutrophil count, said Dr. Barbara Andreola of the University of Padova, Italy, and her coinvestigators. CRP has long been studied as a sensitive marker of bacterial infection, and there has been mounting interest in PCT. The aim of this study was to investigate their diagnostic use, compared with the current markers being used.

The prospective observational study included 404 infants and children younger than 3 years who were admitted to an emergency department with fever of unknown origin. The patients' median age was 10 months; 107 were infants younger than 3 months. Duration of fever was less than 24 hours in 143 children and less than 8 hours in 45 children (Ped. Infect. Dis. J. 2007;26:672–77).

A final diagnosis of severe bacterial infection (SBI) was made in 94 patients (23%); among those without SBI, 16% had focal bacterial infections, 9% had proven viral infections; and the rest of the patients had probable viral infections.

Blood work included tests for PCT and CRP levels, as well as white blood cell and absolute neutrophil counts. In a multivariate regression analysis, PCT and CRP were significantly better predictors of severe bacterial infection than cell counts or clinical assessment. An elevated white blood count was associated with twice the risk for SBI, while an elevated neutrophil count was associated with an increased SBI risk of 38%.

At a cut-off of 1 ng/mL, PCT was associated with a 6-fold increase in the risk of a severe bacterial infection, while a level of more than 2 ng/ml was associated with a more than 13-fold increased risk.

A CRP of more than 40 mg/L was associated with a fourfold increase in the risk of SBI, while a level of more than 80 mg/L was associated with more than an eightfold increased risk.

PCT also predicted specific organ involvement, Dr. Andreola and her associates said, with the highest values found in sepsis and meningitis. In children with fever of less than 8 hours' duration, PCT was the best predictor of SBI. “PCT seems to be a more accurate predictor at the beginning of an infection whereas CRP, if correctly employed by taking into account the time needed for its rise in the bloodstream, may be a better screening test in emergency settings, because of its overall better sensitivity and feasibility—its lower cost, better availability, and better historical practice,” they said.

Elevated procalcitonin and C-reactive protein are highly predictive of a severe bacterial infection in infants and young children admitted to the emergency department with fever without a source, investigators reported.

With their optimal cutoff points, procalcitonin (PCT) and C-reactive protein (CRP) had both better sensitivity and specificity for severe bacterial infections than either white blood cell or absolute neutrophil count, said Dr. Barbara Andreola of the University of Padova, Italy, and her coinvestigators. CRP has long been studied as a sensitive marker of bacterial infection, and there has been mounting interest in PCT. The aim of this study was to investigate their diagnostic use, compared with the current markers being used.

The prospective observational study included 404 infants and children younger than 3 years who were admitted to an emergency department with fever of unknown origin. The patients' median age was 10 months; 107 were infants younger than 3 months. Duration of fever was less than 24 hours in 143 children and less than 8 hours in 45 children (Ped. Infect. Dis. J. 2007;26:672–77).

A final diagnosis of severe bacterial infection (SBI) was made in 94 patients (23%); among those without SBI, 16% had focal bacterial infections, 9% had proven viral infections; and the rest of the patients had probable viral infections.

Blood work included tests for PCT and CRP levels, as well as white blood cell and absolute neutrophil counts. In a multivariate regression analysis, PCT and CRP were significantly better predictors of severe bacterial infection than cell counts or clinical assessment. An elevated white blood count was associated with twice the risk for SBI, while an elevated neutrophil count was associated with an increased SBI risk of 38%.

At a cut-off of 1 ng/mL, PCT was associated with a 6-fold increase in the risk of a severe bacterial infection, while a level of more than 2 ng/ml was associated with a more than 13-fold increased risk.

A CRP of more than 40 mg/L was associated with a fourfold increase in the risk of SBI, while a level of more than 80 mg/L was associated with more than an eightfold increased risk.

PCT also predicted specific organ involvement, Dr. Andreola and her associates said, with the highest values found in sepsis and meningitis. In children with fever of less than 8 hours' duration, PCT was the best predictor of SBI. “PCT seems to be a more accurate predictor at the beginning of an infection whereas CRP, if correctly employed by taking into account the time needed for its rise in the bloodstream, may be a better screening test in emergency settings, because of its overall better sensitivity and feasibility—its lower cost, better availability, and better historical practice,” they said.

Elevated procalcitonin and C-reactive protein are highly predictive of a severe bacterial infection in infants and young children admitted to the emergency department with fever without a source, investigators reported.

With their optimal cutoff points, procalcitonin (PCT) and C-reactive protein (CRP) had both better sensitivity and specificity for severe bacterial infections than either white blood cell or absolute neutrophil count, said Dr. Barbara Andreola of the University of Padova, Italy, and her coinvestigators. CRP has long been studied as a sensitive marker of bacterial infection, and there has been mounting interest in PCT. The aim of this study was to investigate their diagnostic use, compared with the current markers being used.

The prospective observational study included 404 infants and children younger than 3 years who were admitted to an emergency department with fever of unknown origin. The patients' median age was 10 months; 107 were infants younger than 3 months. Duration of fever was less than 24 hours in 143 children and less than 8 hours in 45 children (Ped. Infect. Dis. J. 2007;26:672–77).

A final diagnosis of severe bacterial infection (SBI) was made in 94 patients (23%); among those without SBI, 16% had focal bacterial infections, 9% had proven viral infections; and the rest of the patients had probable viral infections.

Blood work included tests for PCT and CRP levels, as well as white blood cell and absolute neutrophil counts. In a multivariate regression analysis, PCT and CRP were significantly better predictors of severe bacterial infection than cell counts or clinical assessment. An elevated white blood count was associated with twice the risk for SBI, while an elevated neutrophil count was associated with an increased SBI risk of 38%.

At a cut-off of 1 ng/mL, PCT was associated with a 6-fold increase in the risk of a severe bacterial infection, while a level of more than 2 ng/ml was associated with a more than 13-fold increased risk.

A CRP of more than 40 mg/L was associated with a fourfold increase in the risk of SBI, while a level of more than 80 mg/L was associated with more than an eightfold increased risk.

PCT also predicted specific organ involvement, Dr. Andreola and her associates said, with the highest values found in sepsis and meningitis. In children with fever of less than 8 hours' duration, PCT was the best predictor of SBI. “PCT seems to be a more accurate predictor at the beginning of an infection whereas CRP, if correctly employed by taking into account the time needed for its rise in the bloodstream, may be a better screening test in emergency settings, because of its overall better sensitivity and feasibility—its lower cost, better availability, and better historical practice,” they said.

CHICAGO – Women with migraine who have experienced emotional abuse, either recently or in the past, report higher levels of comorbid depression and headache-related disability, Dr. Gretchen E. Tietjen said at the annual meeting of the American Headache Society.

The finding stimulates even more provocative questions about the connections between body and mind, she said. “Changes in the brain due to past abuse have been well documented,” said Dr. Tietjen, professor and chair of the department of neurology at the University of Toledo, Ohio. “You can't separate mental and physical health in these women. What we would like to know is how these changes affect headache and depression, and the common neurobiology that links them.”

She administered a survey that examined a history of emotional, physical, and sexual abuse, as well as headache characteristics, disability, somatic symptoms, and depression, to 1,032 women who sought care at a headache clinic. She divided the description of emotional abuse into six categories: threatening, aggressive, harassing, intimidating, isolating, and coercive/controlling.

Of the study group, 593 (57%) reported episodic headache (96% with migraine). The remainder reported chronic headache (87% with migraine).

Many of the women (43%) reported that they had experienced some kind of emotional abuse, and 6% of the group reported having been exposed to all six types. More than a third of the patients (37%) also reported a history of sexual abuse, with 18% describing a childhood or adolescent experience.

Dr. Tietjen saw a dose-response relationship: The more types of abuse the woman had experienced, the more severe or frequent her headaches and the greater number of additional symptoms she reported. Among those who denied a history of physical or sexual abuse, emotional abuse was associated with higher depression scores, which increased with an increase in the number of types of emotional abuse experienced.

Women who reported remote physical or sexual abuse seemed particularly vulnerable to the effects of later emotional abuse, with greater depression levels, higher stress, more somatic symptoms, and greater headache-related disability. All of these scores exhibited a dose-response relationship to the number of abusive behaviors the women experienced.

Questions about past and current abuse–both physical and emotional–should be part of a headache work-up for every patient, Dr. Tietjen said. “First, if a person is in an unsafe environment, we want to try and get her out. But a history of this experience may also change the type of therapy we offer.”

These patients may respond well to cognitive-behavioral and physical therapy as adjunctive treatments, Dr. Tietjen said.

CHICAGO – Women with migraine who have experienced emotional abuse, either recently or in the past, report higher levels of comorbid depression and headache-related disability, Dr. Gretchen E. Tietjen said at the annual meeting of the American Headache Society.

The finding stimulates even more provocative questions about the connections between body and mind, she said. “Changes in the brain due to past abuse have been well documented,” said Dr. Tietjen, professor and chair of the department of neurology at the University of Toledo, Ohio. “You can't separate mental and physical health in these women. What we would like to know is how these changes affect headache and depression, and the common neurobiology that links them.”

She administered a survey that examined a history of emotional, physical, and sexual abuse, as well as headache characteristics, disability, somatic symptoms, and depression, to 1,032 women who sought care at a headache clinic. She divided the description of emotional abuse into six categories: threatening, aggressive, harassing, intimidating, isolating, and coercive/controlling.

Of the study group, 593 (57%) reported episodic headache (96% with migraine). The remainder reported chronic headache (87% with migraine).

Many of the women (43%) reported that they had experienced some kind of emotional abuse, and 6% of the group reported having been exposed to all six types. More than a third of the patients (37%) also reported a history of sexual abuse, with 18% describing a childhood or adolescent experience.

Dr. Tietjen saw a dose-response relationship: The more types of abuse the woman had experienced, the more severe or frequent her headaches and the greater number of additional symptoms she reported. Among those who denied a history of physical or sexual abuse, emotional abuse was associated with higher depression scores, which increased with an increase in the number of types of emotional abuse experienced.

Women who reported remote physical or sexual abuse seemed particularly vulnerable to the effects of later emotional abuse, with greater depression levels, higher stress, more somatic symptoms, and greater headache-related disability. All of these scores exhibited a dose-response relationship to the number of abusive behaviors the women experienced.

Questions about past and current abuse–both physical and emotional–should be part of a headache work-up for every patient, Dr. Tietjen said. “First, if a person is in an unsafe environment, we want to try and get her out. But a history of this experience may also change the type of therapy we offer.”

These patients may respond well to cognitive-behavioral and physical therapy as adjunctive treatments, Dr. Tietjen said.

CHICAGO – Women with migraine who have experienced emotional abuse, either recently or in the past, report higher levels of comorbid depression and headache-related disability, Dr. Gretchen E. Tietjen said at the annual meeting of the American Headache Society.

The finding stimulates even more provocative questions about the connections between body and mind, she said. “Changes in the brain due to past abuse have been well documented,” said Dr. Tietjen, professor and chair of the department of neurology at the University of Toledo, Ohio. “You can't separate mental and physical health in these women. What we would like to know is how these changes affect headache and depression, and the common neurobiology that links them.”

She administered a survey that examined a history of emotional, physical, and sexual abuse, as well as headache characteristics, disability, somatic symptoms, and depression, to 1,032 women who sought care at a headache clinic. She divided the description of emotional abuse into six categories: threatening, aggressive, harassing, intimidating, isolating, and coercive/controlling.

Of the study group, 593 (57%) reported episodic headache (96% with migraine). The remainder reported chronic headache (87% with migraine).

Many of the women (43%) reported that they had experienced some kind of emotional abuse, and 6% of the group reported having been exposed to all six types. More than a third of the patients (37%) also reported a history of sexual abuse, with 18% describing a childhood or adolescent experience.

Dr. Tietjen saw a dose-response relationship: The more types of abuse the woman had experienced, the more severe or frequent her headaches and the greater number of additional symptoms she reported. Among those who denied a history of physical or sexual abuse, emotional abuse was associated with higher depression scores, which increased with an increase in the number of types of emotional abuse experienced.

Women who reported remote physical or sexual abuse seemed particularly vulnerable to the effects of later emotional abuse, with greater depression levels, higher stress, more somatic symptoms, and greater headache-related disability. All of these scores exhibited a dose-response relationship to the number of abusive behaviors the women experienced.

Questions about past and current abuse–both physical and emotional–should be part of a headache work-up for every patient, Dr. Tietjen said. “First, if a person is in an unsafe environment, we want to try and get her out. But a history of this experience may also change the type of therapy we offer.”

These patients may respond well to cognitive-behavioral and physical therapy as adjunctive treatments, Dr. Tietjen said.

CHICAGO – Patients who frequently call their headache specialty clinic are more likely to be taking multiple opioids in higher doses, potency, and quantity than those who do not call frequently, Karen Fisher, R.N., said at the annual meeting of the American Headache Society.

Ms. Fisher and her colleagues of the headache clinic at the University of North Carolina at Chapel Hill researched their database to identify common characteristics of patients who called frequently (at least 20 times in a calendar year) and those who did not (no calls within a calendar year). High-frequency (26) and low-frequency callers (18) were similar in age (about 42 years), marital status, ethnicity, and diagnosis. There was a nonsignificant trend for more females in the frequent-caller group. Migraine was the most frequent diagnosis in each group. All patients had been followed for at least 5 years.

Calls included requests for refills, complaints that medication was not working, and requests for different medications, among other topics.

The patients were similar in their use of triptans and botulinum toxin. But significantly more of the frequent callers were taking opioids (96% vs. 11%).

Frequent callers also were more likely to be taking multiple opioids of higher potency and dose. To further investigate the relationship of opioid strength to calling frequency, the researchers assigned morphine equivalency strength to each milligram of opioid prescribed. (See box.)

Frequent callers were taking significantly more daily morphine equivalents than nonfrequent callers were (154.4 mg vs. 1.4 mg).

“Further research is needed to explore the relative contributions of psychological characteristics, burden of illness, or other factors [that] might contribute to the excessive calling, which is associated with negative perceptions on the part of headache clinic staff and caregivers,” Ms. Fisher said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Patients who frequently call their headache specialty clinic are more likely to be taking multiple opioids in higher doses, potency, and quantity than those who do not call frequently, Karen Fisher, R.N., said at the annual meeting of the American Headache Society.

Ms. Fisher and her colleagues of the headache clinic at the University of North Carolina at Chapel Hill researched their database to identify common characteristics of patients who called frequently (at least 20 times in a calendar year) and those who did not (no calls within a calendar year). High-frequency (26) and low-frequency callers (18) were similar in age (about 42 years), marital status, ethnicity, and diagnosis. There was a nonsignificant trend for more females in the frequent-caller group. Migraine was the most frequent diagnosis in each group. All patients had been followed for at least 5 years.

Calls included requests for refills, complaints that medication was not working, and requests for different medications, among other topics.

The patients were similar in their use of triptans and botulinum toxin. But significantly more of the frequent callers were taking opioids (96% vs. 11%).

Frequent callers also were more likely to be taking multiple opioids of higher potency and dose. To further investigate the relationship of opioid strength to calling frequency, the researchers assigned morphine equivalency strength to each milligram of opioid prescribed. (See box.)

Frequent callers were taking significantly more daily morphine equivalents than nonfrequent callers were (154.4 mg vs. 1.4 mg).

“Further research is needed to explore the relative contributions of psychological characteristics, burden of illness, or other factors [that] might contribute to the excessive calling, which is associated with negative perceptions on the part of headache clinic staff and caregivers,” Ms. Fisher said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Patients who frequently call their headache specialty clinic are more likely to be taking multiple opioids in higher doses, potency, and quantity than those who do not call frequently, Karen Fisher, R.N., said at the annual meeting of the American Headache Society.

Ms. Fisher and her colleagues of the headache clinic at the University of North Carolina at Chapel Hill researched their database to identify common characteristics of patients who called frequently (at least 20 times in a calendar year) and those who did not (no calls within a calendar year). High-frequency (26) and low-frequency callers (18) were similar in age (about 42 years), marital status, ethnicity, and diagnosis. There was a nonsignificant trend for more females in the frequent-caller group. Migraine was the most frequent diagnosis in each group. All patients had been followed for at least 5 years.

Calls included requests for refills, complaints that medication was not working, and requests for different medications, among other topics.

The patients were similar in their use of triptans and botulinum toxin. But significantly more of the frequent callers were taking opioids (96% vs. 11%).

Frequent callers also were more likely to be taking multiple opioids of higher potency and dose. To further investigate the relationship of opioid strength to calling frequency, the researchers assigned morphine equivalency strength to each milligram of opioid prescribed. (See box.)

Frequent callers were taking significantly more daily morphine equivalents than nonfrequent callers were (154.4 mg vs. 1.4 mg).

“Further research is needed to explore the relative contributions of psychological characteristics, burden of illness, or other factors [that] might contribute to the excessive calling, which is associated with negative perceptions on the part of headache clinic staff and caregivers,” Ms. Fisher said.

ELSEVIER GLOBAL MEDICAL NEWS

Sexual dysfunction is quite common in women with epilepsy, just as ignoring the problem is quite common among their physicians, experts say.

Naturally, said Dr. Romila Mushtaq, an epileptologist at the Medical College of Wisconsin, Milwaukee, the first concern of the neurologist in epilepsy is controlling seizures. The issue of sexual well-being can become a low priority. But studies repeatedly show that 30% or more of women with epilepsy–even well-controlled epilepsy–experience troubles with libido, arousal, orgasm, genital lubrication, and dyspareunia.

Often, just a few simple questions can uncover a cascade of troublesome issues. “It's humbling how many women will spend most of their appointment time questioning me about their sexual health, because no one has ever talked to them before, and they were shy or never even thought to bring it up,” Dr. Mushtaq said in an interview.

Her own recent study, presented at the annual meeting of the American Academy of Neurology, clearly illustrated the scope of the problem. Dr. Mushtaq reported on 105 women with epilepsy who completed a comprehensive health questionnaire. The assessment included questions about decreased libido, pain during intercourse, difficulty becoming aroused, and difficulty or inability reaching orgasm. Women with diagnosed depression were excluded.

Almost 40% of the respondents reported at least one symptom of sexual dysfunction, Dr. Mushtaq said. The most commonly reported problems were decreased libido and difficulty obtaining orgasm.

Some antiepileptic drugs–particularly the older medications–interfere with sexual response because they affect the hypothalamic-pituitary-adrenal axis and induce hepatic enzymes (Psychiatry 2007;6:111–4). But Dr. Mushtaq's study found no association between sexual problems and the type of antiepileptic medication, although patients on polytherapy were more likely to express symptoms than were those on monotherapy.

It might be easy to conclude that some sexual problems are psychological, she said: The depression and anxiety of having a chronic disease can manifest as sexual dysfunction. But multiple studies show a complex link between epilepsy (a disorder of the brain) and sexual response (a function of the brain). The reasons for epilepsy-related sexual problems are varied and complicated. Antiepileptic drugs, disruption of the hypothalamic-pituitary-ovarian axis, hormonal fluctuations, and even seizure locus can all affect the way women experience their sexuality.

Arousal issues may be related to decrease in blood flow to the genitals, Dr. Mushtaq said. A 1994 study explored this area with a group of 36 subjects: nine women and eight men with temporal lobe epilepsy and 19 controls (Neurology 1994;44:243–7).

The subjects watched both sexually neutral and erotic videotapes while undergoing digital pulse and genital blood flow readings. Despite similar pulse rates, both male and female patients experienced significantly less genital blood flow response than did controls (184% vs. 660% for males, and 117% vs. 161% for females).

The effect of epilepsy on hormones plays a large part in sexuality, she said. “Problems with orgasm are probably related to a lack of testosterone. Epilepsy can disrupt the pulsatile release of follicle-stimulating hormone,” a precursor of testosterone production. This disruption can also occur in men with epilepsy, but it isn't always profound enough to cause erectile dysfunction. “But in women, even a slight change can affect arousal, libido, and orgasm,” she said.

Epilepsy and hormones present a chicken-or-egg scenario. While seizures can disrupt hormonal balance, neurons in the epileptic brain can also become hypersensitive to hormones, a force that seems to drive both catamenial epilepsy (a pattern of seizures that peaks near the time of menstruation) and the high prevalence of premenstrual dysphoric disorder (PMDD) in this population.

Dr. Andrew Herzog, a neurologist and director of the neuroendocrine unit at Beth Israel Deaconess Medical Center, Boston, has published extensively on the relationship between hormones and epilepsy. At the AAN meeting, he also presented an observational study on premenstrual dysphoric disorder in women with epilepsy. His study examined the rate of PMDD in 250 women with refractory epilepsy. The rate was 32%, which is three times higher than the 10% rate seen in the general population.

The cyclical fluctuations of estrogen and progesterone probably drive this association, Dr. Herzog said. Estrogen enhances neuronal excitability and lowers the seizure threshold, whereas progesterone decreases excitability and raises the seizure threshold. Normally, these effects stabilize one another, balancing neuronal excitability. “In brains that are sensitized due to injury, congenital factors, or epilepsy, however, these responses are heightened. When estrogen surges at midcycle, it can produce highly excitatory, agitated, irritable behaviors. When progesterone declines close to menstruation, its GABAergic effect is rapidly withdrawn and this can also drive excitation.”

These effects can be further heightened in women whose seizures arise in a brain region related to emotion, such as the temporal lobe, he added.

Seizure locus also seems to be related to the type of sexual dysfunction a woman may experience, Dr. Herzog said. In 2003, he examined this relationship in 36 women with right or left temporal lobe epilepsy and 12 controls. All of the women completed the Arizona Sexual Experience Scale (ASEX). They also received continuous EEG recordings for 8 hours, during which 5-cc blood samples were drawn every 10 minutes.

The ASEX scores were significantly higher (worse) in women with epilepsy than in controls; women with right temporal lobe epilepsy (RTLE) had higher scores than did those with left TLE.

A significant number of women with epilepsy also had subnormal gonadal steroid levels. Women with RTLE tended to have low levels of bioactive testosterone, whereas those with LTLE were more likely to have low estradiol.

The association of sexual dysfunction and laterality of seizure locus supports a biologic brain-based mechanism, Dr. Herzog wrote. “There is increasing evidence to support the existence of lateralized brain asymmetries in the regulation of neuroendocrine, reproductive, and sexual functions” in animal studies. For instance, he noted, female rat brains contain up to 100% more gonadotropin-releasing hormone content in the right side of the hypothalamus than in the left.

The finding of more sexual dysfunction with RTLE may reflect a similar lateralized asymmetry in areas of the human hypothalamus that influence sexual function, he wrote, especially because unilateral epileptiform discharges tend to affect the hypothalamus ipsilaterally.

The understanding of epilepsy's influence on hormones and sexuality is still in its infancy, Dr. Mushtaq said. “As research continues to unfold, we are likely to discover that this is also the factor behind the fertility problems women with epilepsy can experience.”

In the meantime, clinicians should be vigilant about screening these women for sexual difficulties, and referring them to specialists. “When do [neurologists] ever ask patients about their sex life, or about their premenstrual emotional problems?” she said. “It's a topic that has been almost taboo.”

Sexual dysfunction is quite common in women with epilepsy, just as ignoring the problem is quite common among their physicians, experts say.

Naturally, said Dr. Romila Mushtaq, an epileptologist at the Medical College of Wisconsin, Milwaukee, the first concern of the neurologist in epilepsy is controlling seizures. The issue of sexual well-being can become a low priority. But studies repeatedly show that 30% or more of women with epilepsy–even well-controlled epilepsy–experience troubles with libido, arousal, orgasm, genital lubrication, and dyspareunia.

Often, just a few simple questions can uncover a cascade of troublesome issues. “It's humbling how many women will spend most of their appointment time questioning me about their sexual health, because no one has ever talked to them before, and they were shy or never even thought to bring it up,” Dr. Mushtaq said in an interview.

Her own recent study, presented at the annual meeting of the American Academy of Neurology, clearly illustrated the scope of the problem. Dr. Mushtaq reported on 105 women with epilepsy who completed a comprehensive health questionnaire. The assessment included questions about decreased libido, pain during intercourse, difficulty becoming aroused, and difficulty or inability reaching orgasm. Women with diagnosed depression were excluded.

Almost 40% of the respondents reported at least one symptom of sexual dysfunction, Dr. Mushtaq said. The most commonly reported problems were decreased libido and difficulty obtaining orgasm.

Some antiepileptic drugs–particularly the older medications–interfere with sexual response because they affect the hypothalamic-pituitary-adrenal axis and induce hepatic enzymes (Psychiatry 2007;6:111–4). But Dr. Mushtaq's study found no association between sexual problems and the type of antiepileptic medication, although patients on polytherapy were more likely to express symptoms than were those on monotherapy.

It might be easy to conclude that some sexual problems are psychological, she said: The depression and anxiety of having a chronic disease can manifest as sexual dysfunction. But multiple studies show a complex link between epilepsy (a disorder of the brain) and sexual response (a function of the brain). The reasons for epilepsy-related sexual problems are varied and complicated. Antiepileptic drugs, disruption of the hypothalamic-pituitary-ovarian axis, hormonal fluctuations, and even seizure locus can all affect the way women experience their sexuality.

Arousal issues may be related to decrease in blood flow to the genitals, Dr. Mushtaq said. A 1994 study explored this area with a group of 36 subjects: nine women and eight men with temporal lobe epilepsy and 19 controls (Neurology 1994;44:243–7).

The subjects watched both sexually neutral and erotic videotapes while undergoing digital pulse and genital blood flow readings. Despite similar pulse rates, both male and female patients experienced significantly less genital blood flow response than did controls (184% vs. 660% for males, and 117% vs. 161% for females).

The effect of epilepsy on hormones plays a large part in sexuality, she said. “Problems with orgasm are probably related to a lack of testosterone. Epilepsy can disrupt the pulsatile release of follicle-stimulating hormone,” a precursor of testosterone production. This disruption can also occur in men with epilepsy, but it isn't always profound enough to cause erectile dysfunction. “But in women, even a slight change can affect arousal, libido, and orgasm,” she said.

Epilepsy and hormones present a chicken-or-egg scenario. While seizures can disrupt hormonal balance, neurons in the epileptic brain can also become hypersensitive to hormones, a force that seems to drive both catamenial epilepsy (a pattern of seizures that peaks near the time of menstruation) and the high prevalence of premenstrual dysphoric disorder (PMDD) in this population.

Dr. Andrew Herzog, a neurologist and director of the neuroendocrine unit at Beth Israel Deaconess Medical Center, Boston, has published extensively on the relationship between hormones and epilepsy. At the AAN meeting, he also presented an observational study on premenstrual dysphoric disorder in women with epilepsy. His study examined the rate of PMDD in 250 women with refractory epilepsy. The rate was 32%, which is three times higher than the 10% rate seen in the general population.

The cyclical fluctuations of estrogen and progesterone probably drive this association, Dr. Herzog said. Estrogen enhances neuronal excitability and lowers the seizure threshold, whereas progesterone decreases excitability and raises the seizure threshold. Normally, these effects stabilize one another, balancing neuronal excitability. “In brains that are sensitized due to injury, congenital factors, or epilepsy, however, these responses are heightened. When estrogen surges at midcycle, it can produce highly excitatory, agitated, irritable behaviors. When progesterone declines close to menstruation, its GABAergic effect is rapidly withdrawn and this can also drive excitation.”

These effects can be further heightened in women whose seizures arise in a brain region related to emotion, such as the temporal lobe, he added.

Seizure locus also seems to be related to the type of sexual dysfunction a woman may experience, Dr. Herzog said. In 2003, he examined this relationship in 36 women with right or left temporal lobe epilepsy and 12 controls. All of the women completed the Arizona Sexual Experience Scale (ASEX). They also received continuous EEG recordings for 8 hours, during which 5-cc blood samples were drawn every 10 minutes.

The ASEX scores were significantly higher (worse) in women with epilepsy than in controls; women with right temporal lobe epilepsy (RTLE) had higher scores than did those with left TLE.

A significant number of women with epilepsy also had subnormal gonadal steroid levels. Women with RTLE tended to have low levels of bioactive testosterone, whereas those with LTLE were more likely to have low estradiol.

The association of sexual dysfunction and laterality of seizure locus supports a biologic brain-based mechanism, Dr. Herzog wrote. “There is increasing evidence to support the existence of lateralized brain asymmetries in the regulation of neuroendocrine, reproductive, and sexual functions” in animal studies. For instance, he noted, female rat brains contain up to 100% more gonadotropin-releasing hormone content in the right side of the hypothalamus than in the left.

The finding of more sexual dysfunction with RTLE may reflect a similar lateralized asymmetry in areas of the human hypothalamus that influence sexual function, he wrote, especially because unilateral epileptiform discharges tend to affect the hypothalamus ipsilaterally.

The understanding of epilepsy's influence on hormones and sexuality is still in its infancy, Dr. Mushtaq said. “As research continues to unfold, we are likely to discover that this is also the factor behind the fertility problems women with epilepsy can experience.”

In the meantime, clinicians should be vigilant about screening these women for sexual difficulties, and referring them to specialists. “When do [neurologists] ever ask patients about their sex life, or about their premenstrual emotional problems?” she said. “It's a topic that has been almost taboo.”

Sexual dysfunction is quite common in women with epilepsy, just as ignoring the problem is quite common among their physicians, experts say.

Naturally, said Dr. Romila Mushtaq, an epileptologist at the Medical College of Wisconsin, Milwaukee, the first concern of the neurologist in epilepsy is controlling seizures. The issue of sexual well-being can become a low priority. But studies repeatedly show that 30% or more of women with epilepsy–even well-controlled epilepsy–experience troubles with libido, arousal, orgasm, genital lubrication, and dyspareunia.

Often, just a few simple questions can uncover a cascade of troublesome issues. “It's humbling how many women will spend most of their appointment time questioning me about their sexual health, because no one has ever talked to them before, and they were shy or never even thought to bring it up,” Dr. Mushtaq said in an interview.

Her own recent study, presented at the annual meeting of the American Academy of Neurology, clearly illustrated the scope of the problem. Dr. Mushtaq reported on 105 women with epilepsy who completed a comprehensive health questionnaire. The assessment included questions about decreased libido, pain during intercourse, difficulty becoming aroused, and difficulty or inability reaching orgasm. Women with diagnosed depression were excluded.

Almost 40% of the respondents reported at least one symptom of sexual dysfunction, Dr. Mushtaq said. The most commonly reported problems were decreased libido and difficulty obtaining orgasm.

Some antiepileptic drugs–particularly the older medications–interfere with sexual response because they affect the hypothalamic-pituitary-adrenal axis and induce hepatic enzymes (Psychiatry 2007;6:111–4). But Dr. Mushtaq's study found no association between sexual problems and the type of antiepileptic medication, although patients on polytherapy were more likely to express symptoms than were those on monotherapy.

It might be easy to conclude that some sexual problems are psychological, she said: The depression and anxiety of having a chronic disease can manifest as sexual dysfunction. But multiple studies show a complex link between epilepsy (a disorder of the brain) and sexual response (a function of the brain). The reasons for epilepsy-related sexual problems are varied and complicated. Antiepileptic drugs, disruption of the hypothalamic-pituitary-ovarian axis, hormonal fluctuations, and even seizure locus can all affect the way women experience their sexuality.

Arousal issues may be related to decrease in blood flow to the genitals, Dr. Mushtaq said. A 1994 study explored this area with a group of 36 subjects: nine women and eight men with temporal lobe epilepsy and 19 controls (Neurology 1994;44:243–7).

The subjects watched both sexually neutral and erotic videotapes while undergoing digital pulse and genital blood flow readings. Despite similar pulse rates, both male and female patients experienced significantly less genital blood flow response than did controls (184% vs. 660% for males, and 117% vs. 161% for females).

The effect of epilepsy on hormones plays a large part in sexuality, she said. “Problems with orgasm are probably related to a lack of testosterone. Epilepsy can disrupt the pulsatile release of follicle-stimulating hormone,” a precursor of testosterone production. This disruption can also occur in men with epilepsy, but it isn't always profound enough to cause erectile dysfunction. “But in women, even a slight change can affect arousal, libido, and orgasm,” she said.

Epilepsy and hormones present a chicken-or-egg scenario. While seizures can disrupt hormonal balance, neurons in the epileptic brain can also become hypersensitive to hormones, a force that seems to drive both catamenial epilepsy (a pattern of seizures that peaks near the time of menstruation) and the high prevalence of premenstrual dysphoric disorder (PMDD) in this population.

Dr. Andrew Herzog, a neurologist and director of the neuroendocrine unit at Beth Israel Deaconess Medical Center, Boston, has published extensively on the relationship between hormones and epilepsy. At the AAN meeting, he also presented an observational study on premenstrual dysphoric disorder in women with epilepsy. His study examined the rate of PMDD in 250 women with refractory epilepsy. The rate was 32%, which is three times higher than the 10% rate seen in the general population.

The cyclical fluctuations of estrogen and progesterone probably drive this association, Dr. Herzog said. Estrogen enhances neuronal excitability and lowers the seizure threshold, whereas progesterone decreases excitability and raises the seizure threshold. Normally, these effects stabilize one another, balancing neuronal excitability. “In brains that are sensitized due to injury, congenital factors, or epilepsy, however, these responses are heightened. When estrogen surges at midcycle, it can produce highly excitatory, agitated, irritable behaviors. When progesterone declines close to menstruation, its GABAergic effect is rapidly withdrawn and this can also drive excitation.”

These effects can be further heightened in women whose seizures arise in a brain region related to emotion, such as the temporal lobe, he added.

Seizure locus also seems to be related to the type of sexual dysfunction a woman may experience, Dr. Herzog said. In 2003, he examined this relationship in 36 women with right or left temporal lobe epilepsy and 12 controls. All of the women completed the Arizona Sexual Experience Scale (ASEX). They also received continuous EEG recordings for 8 hours, during which 5-cc blood samples were drawn every 10 minutes.

The ASEX scores were significantly higher (worse) in women with epilepsy than in controls; women with right temporal lobe epilepsy (RTLE) had higher scores than did those with left TLE.

A significant number of women with epilepsy also had subnormal gonadal steroid levels. Women with RTLE tended to have low levels of bioactive testosterone, whereas those with LTLE were more likely to have low estradiol.

The association of sexual dysfunction and laterality of seizure locus supports a biologic brain-based mechanism, Dr. Herzog wrote. “There is increasing evidence to support the existence of lateralized brain asymmetries in the regulation of neuroendocrine, reproductive, and sexual functions” in animal studies. For instance, he noted, female rat brains contain up to 100% more gonadotropin-releasing hormone content in the right side of the hypothalamus than in the left.

The finding of more sexual dysfunction with RTLE may reflect a similar lateralized asymmetry in areas of the human hypothalamus that influence sexual function, he wrote, especially because unilateral epileptiform discharges tend to affect the hypothalamus ipsilaterally.

The understanding of epilepsy's influence on hormones and sexuality is still in its infancy, Dr. Mushtaq said. “As research continues to unfold, we are likely to discover that this is also the factor behind the fertility problems women with epilepsy can experience.”

In the meantime, clinicians should be vigilant about screening these women for sexual difficulties, and referring them to specialists. “When do [neurologists] ever ask patients about their sex life, or about their premenstrual emotional problems?” she said. “It's a topic that has been almost taboo.”

CHICAGO – Paroxetine can take the anxiety out of the drinker, but it cannot take the drinking out of the anxious person.

The drug did uncouple anxiety and drinking in patients who use alcohol to cope with severe generalized social anxiety, Dr. Sarah Book said at the annual meeting of the Research Society on Alcoholism. But compared with placebo, paroxetine (Paxil) had no effect on overall alcohol consumption.

“These patients were precontemplators for their alcohol use disorder,” said Dr. Book, a psychiatrist at the Medical University of South Carolina, Charleston. “They wanted us to fix their anxiety symptoms but weren't interested in addressing their alcoholism.”

Her 16-week randomized controlled trial, funded by the National Institute of Alcohol Abuse and Alcoholism, pitted paroxetine (60 mg) against placebo in 42 patients with severe generalized anxiety and comorbid alcohol use disorders. The patients could have had no previous alcohol detoxification treatment. “We wanted to examine the effect of the drug in people who were early in their alcoholism career, to see if we could intervene in the progression,” she said.

The patients' average age was 29 years; 50% were male. At baseline, their mean score on the Leibowitz Social Anxiety Scale (LSAS) was about 90, indicating severe social anxiety. Anxiety had its onset at age 12 years in these patients; the use of alcohol to cope with symptoms followed about a decade later. They were moderately dependent on alcohol, consuming about 15 drinks per week.

By week 16, patients in the treatment group had a far greater decrease in their LSAS scores than did those in the placebo group (53% vs. 32%). But a different picture emerged when Dr. Book examined the drug's effect on drinking.

All patients completed a study-specific questionnaire that asked how often they drank to cope before and during social situations. At week 16, those in the paroxetine group had significantly lower scores than did those in the placebo group, with 20% (vs. 40%) saying they still drank to cope with social situations, and 30% (vs. 70%) saying they would avoid such situations if they couldn't drink.

But when Dr. Book examined the total overall drinking, no differences were found between the groups in either frequency of drinking or quantity consumed.

GlaxoSmithKline Inc. provided the study medication.

CHICAGO – Paroxetine can take the anxiety out of the drinker, but it cannot take the drinking out of the anxious person.

The drug did uncouple anxiety and drinking in patients who use alcohol to cope with severe generalized social anxiety, Dr. Sarah Book said at the annual meeting of the Research Society on Alcoholism. But compared with placebo, paroxetine (Paxil) had no effect on overall alcohol consumption.

“These patients were precontemplators for their alcohol use disorder,” said Dr. Book, a psychiatrist at the Medical University of South Carolina, Charleston. “They wanted us to fix their anxiety symptoms but weren't interested in addressing their alcoholism.”

Her 16-week randomized controlled trial, funded by the National Institute of Alcohol Abuse and Alcoholism, pitted paroxetine (60 mg) against placebo in 42 patients with severe generalized anxiety and comorbid alcohol use disorders. The patients could have had no previous alcohol detoxification treatment. “We wanted to examine the effect of the drug in people who were early in their alcoholism career, to see if we could intervene in the progression,” she said.

The patients' average age was 29 years; 50% were male. At baseline, their mean score on the Leibowitz Social Anxiety Scale (LSAS) was about 90, indicating severe social anxiety. Anxiety had its onset at age 12 years in these patients; the use of alcohol to cope with symptoms followed about a decade later. They were moderately dependent on alcohol, consuming about 15 drinks per week.

By week 16, patients in the treatment group had a far greater decrease in their LSAS scores than did those in the placebo group (53% vs. 32%). But a different picture emerged when Dr. Book examined the drug's effect on drinking.

All patients completed a study-specific questionnaire that asked how often they drank to cope before and during social situations. At week 16, those in the paroxetine group had significantly lower scores than did those in the placebo group, with 20% (vs. 40%) saying they still drank to cope with social situations, and 30% (vs. 70%) saying they would avoid such situations if they couldn't drink.

But when Dr. Book examined the total overall drinking, no differences were found between the groups in either frequency of drinking or quantity consumed.

GlaxoSmithKline Inc. provided the study medication.

CHICAGO – Paroxetine can take the anxiety out of the drinker, but it cannot take the drinking out of the anxious person.

The drug did uncouple anxiety and drinking in patients who use alcohol to cope with severe generalized social anxiety, Dr. Sarah Book said at the annual meeting of the Research Society on Alcoholism. But compared with placebo, paroxetine (Paxil) had no effect on overall alcohol consumption.

“These patients were precontemplators for their alcohol use disorder,” said Dr. Book, a psychiatrist at the Medical University of South Carolina, Charleston. “They wanted us to fix their anxiety symptoms but weren't interested in addressing their alcoholism.”

Her 16-week randomized controlled trial, funded by the National Institute of Alcohol Abuse and Alcoholism, pitted paroxetine (60 mg) against placebo in 42 patients with severe generalized anxiety and comorbid alcohol use disorders. The patients could have had no previous alcohol detoxification treatment. “We wanted to examine the effect of the drug in people who were early in their alcoholism career, to see if we could intervene in the progression,” she said.

The patients' average age was 29 years; 50% were male. At baseline, their mean score on the Leibowitz Social Anxiety Scale (LSAS) was about 90, indicating severe social anxiety. Anxiety had its onset at age 12 years in these patients; the use of alcohol to cope with symptoms followed about a decade later. They were moderately dependent on alcohol, consuming about 15 drinks per week.

By week 16, patients in the treatment group had a far greater decrease in their LSAS scores than did those in the placebo group (53% vs. 32%). But a different picture emerged when Dr. Book examined the drug's effect on drinking.

All patients completed a study-specific questionnaire that asked how often they drank to cope before and during social situations. At week 16, those in the paroxetine group had significantly lower scores than did those in the placebo group, with 20% (vs. 40%) saying they still drank to cope with social situations, and 30% (vs. 70%) saying they would avoid such situations if they couldn't drink.

But when Dr. Book examined the total overall drinking, no differences were found between the groups in either frequency of drinking or quantity consumed.

GlaxoSmithKline Inc. provided the study medication.