Michele G. Sullivan

WASHINGTON – Childhood epilepsy surgery isn't associated with a long-term improvement in cognitive functioning, Janet Olds, Ph.D., and her colleagues reported in a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

While findings from previous studies have shown that the surgery has no short-term effect on childhood cognition, little was known until now about its long-term effect on adult cognition, noted Dr. Olds, a psychologist at the Children's Hospital of Eastern Ontario.

She assessed cognitive function in 50 adults (mean age 22 years) with a history of childhood epilepsy; 34 had undergone epilepsy surgery at least 2 years prior to assessment.

Of these, 21 were seizure-free and 13 continued to have seizures. The other 16 subjects, who served as controls, had never had surgery for their epilepsy as children and continued to have seizures as adults.

Seizure-free surgical subjects were taking a mean of one antiepileptic drug. Both the surgical group with continued seizures and the nonsurgical group were taking a mean of two antiepileptic drugs.

All of the subjects completed a neuropsychological assessment consisting of measures of intelligence, memory, and executive functioning (Wechsler Adult Intelligence Scale, vocabulary and block design; Wechsler Memory Scale, logical memory and memory for faces; Wisconsin Card Sort Test). Scores were compared with the subjects' pre- and postsurgical scores on the same tests.

There were no group differences in problem solving as reflected in the Wisconsin Card Sort Test. Surgery subjects who continued to have seizures scored lower on vocabulary and verbal memory tests, compared with both the seizure-free surgery group and the no-surgery group.

When the scores in two surgical groups were compared, the seizure-free group did better on vocabulary and block design, compared with the group still having seizures. However, there were no differences in scores across the three test periods, indicating no significant change in functioning over time.

It's important to include a discussion of cognitive function when counseling parents about the potential impact of epilepsy surgery, said Mary Lou Smith, Ph.D., the study's principal investigator. The majority of research suggests that cognitive skills won't change–a fact that can be construed in a positive, as well as potentially negative, light.

“In essence, this is good news, although not necessarily the good news those parents would like to hear,” Dr. Smith, of the University of Toronto, said in an interview. “[Parents] may wish, and often do, that their child will show improved cognitive function after surgery.”

She added that it is important to remember that the study's conclusions are based on group numbers and that within each group, some children do better or worse than the study's findings indicate.

Unfortunately, Dr. Smith said, there's no consensus on what factors predict who will improve and who will deteriorate.

“The few studies that have included a comparison group of children with intractable epilepsy who don't have surgery show that the proportion who shows increases or decreases is the same in both surgical and nonsurgical groups,” she commented.

The general conclusion is that as long as the eloquent cortex remains intact, there is no particular cognitive risk or benefit associated with the surgery, said Dr. Smith.

WASHINGTON – Childhood epilepsy surgery isn't associated with a long-term improvement in cognitive functioning, Janet Olds, Ph.D., and her colleagues reported in a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

While findings from previous studies have shown that the surgery has no short-term effect on childhood cognition, little was known until now about its long-term effect on adult cognition, noted Dr. Olds, a psychologist at the Children's Hospital of Eastern Ontario.

She assessed cognitive function in 50 adults (mean age 22 years) with a history of childhood epilepsy; 34 had undergone epilepsy surgery at least 2 years prior to assessment.

Of these, 21 were seizure-free and 13 continued to have seizures. The other 16 subjects, who served as controls, had never had surgery for their epilepsy as children and continued to have seizures as adults.

Seizure-free surgical subjects were taking a mean of one antiepileptic drug. Both the surgical group with continued seizures and the nonsurgical group were taking a mean of two antiepileptic drugs.

All of the subjects completed a neuropsychological assessment consisting of measures of intelligence, memory, and executive functioning (Wechsler Adult Intelligence Scale, vocabulary and block design; Wechsler Memory Scale, logical memory and memory for faces; Wisconsin Card Sort Test). Scores were compared with the subjects' pre- and postsurgical scores on the same tests.

There were no group differences in problem solving as reflected in the Wisconsin Card Sort Test. Surgery subjects who continued to have seizures scored lower on vocabulary and verbal memory tests, compared with both the seizure-free surgery group and the no-surgery group.

When the scores in two surgical groups were compared, the seizure-free group did better on vocabulary and block design, compared with the group still having seizures. However, there were no differences in scores across the three test periods, indicating no significant change in functioning over time.

It's important to include a discussion of cognitive function when counseling parents about the potential impact of epilepsy surgery, said Mary Lou Smith, Ph.D., the study's principal investigator. The majority of research suggests that cognitive skills won't change–a fact that can be construed in a positive, as well as potentially negative, light.

“In essence, this is good news, although not necessarily the good news those parents would like to hear,” Dr. Smith, of the University of Toronto, said in an interview. “[Parents] may wish, and often do, that their child will show improved cognitive function after surgery.”

She added that it is important to remember that the study's conclusions are based on group numbers and that within each group, some children do better or worse than the study's findings indicate.

Unfortunately, Dr. Smith said, there's no consensus on what factors predict who will improve and who will deteriorate.

“The few studies that have included a comparison group of children with intractable epilepsy who don't have surgery show that the proportion who shows increases or decreases is the same in both surgical and nonsurgical groups,” she commented.

The general conclusion is that as long as the eloquent cortex remains intact, there is no particular cognitive risk or benefit associated with the surgery, said Dr. Smith.

WASHINGTON – Childhood epilepsy surgery isn't associated with a long-term improvement in cognitive functioning, Janet Olds, Ph.D., and her colleagues reported in a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

While findings from previous studies have shown that the surgery has no short-term effect on childhood cognition, little was known until now about its long-term effect on adult cognition, noted Dr. Olds, a psychologist at the Children's Hospital of Eastern Ontario.

She assessed cognitive function in 50 adults (mean age 22 years) with a history of childhood epilepsy; 34 had undergone epilepsy surgery at least 2 years prior to assessment.

Of these, 21 were seizure-free and 13 continued to have seizures. The other 16 subjects, who served as controls, had never had surgery for their epilepsy as children and continued to have seizures as adults.

Seizure-free surgical subjects were taking a mean of one antiepileptic drug. Both the surgical group with continued seizures and the nonsurgical group were taking a mean of two antiepileptic drugs.

All of the subjects completed a neuropsychological assessment consisting of measures of intelligence, memory, and executive functioning (Wechsler Adult Intelligence Scale, vocabulary and block design; Wechsler Memory Scale, logical memory and memory for faces; Wisconsin Card Sort Test). Scores were compared with the subjects' pre- and postsurgical scores on the same tests.

There were no group differences in problem solving as reflected in the Wisconsin Card Sort Test. Surgery subjects who continued to have seizures scored lower on vocabulary and verbal memory tests, compared with both the seizure-free surgery group and the no-surgery group.

When the scores in two surgical groups were compared, the seizure-free group did better on vocabulary and block design, compared with the group still having seizures. However, there were no differences in scores across the three test periods, indicating no significant change in functioning over time.

It's important to include a discussion of cognitive function when counseling parents about the potential impact of epilepsy surgery, said Mary Lou Smith, Ph.D., the study's principal investigator. The majority of research suggests that cognitive skills won't change–a fact that can be construed in a positive, as well as potentially negative, light.

“In essence, this is good news, although not necessarily the good news those parents would like to hear,” Dr. Smith, of the University of Toronto, said in an interview. “[Parents] may wish, and often do, that their child will show improved cognitive function after surgery.”

She added that it is important to remember that the study's conclusions are based on group numbers and that within each group, some children do better or worse than the study's findings indicate.

Unfortunately, Dr. Smith said, there's no consensus on what factors predict who will improve and who will deteriorate.

“The few studies that have included a comparison group of children with intractable epilepsy who don't have surgery show that the proportion who shows increases or decreases is the same in both surgical and nonsurgical groups,” she commented.

The general conclusion is that as long as the eloquent cortex remains intact, there is no particular cognitive risk or benefit associated with the surgery, said Dr. Smith.

TORONTO – Quetiapine appears to improve symptoms of depression and suicidal ideation in adolescents with bipolar disorder, mood disorder, and those at familial risk of developing bipolar disorder, according to a poster presented at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

Dr. Melissa DelBello of the University of Cincinnati and her colleagues presented the results of three studies of the drug in bipolar adolescents aged 12–18 years.

Study 1 included 30 adolescents hospitalized with mixed or manic episodes.

The patients were randomized to divalproex or divalproex plus quetiapine (mean dose 423 mg/day) for 6 weeks.

Those in the combination group experienced a greater mean decrease in depression scores from baseline than did those in the divalproex-only group (from 50 to 24 vs. 50 to 34, respectively).

Study 2 included 50 patients hospitalized with bipolar I disorder (94% mixed, 6% manic episodes).

They were randomized to quetiapine (Seroquel) monotherapy (mean dose 417 mg/day) or divalproex monotherapy for 4 weeks.

Mean depression scores in the quetiapine group decreased from 52 to 25. Dr. DelBello did not analyze the divalproex response in this study.

Study 3 included 25 hospitalized adolescents with a mood disorder and with at least one parent with bipolar disorder.

The adolescents received quetiapine monotherapy (mean dose 447 mg/day) for 12 weeks. Mean depression scores decreased from 40 to 29.

In the three studies, 65 patients who took quetiapine alone had major depression. Overall, their mean suicidality score decreased from 3.0 to 1.5.

The suicidality score increased, however, in two of the patients, both of whom were taking quetiapine.

Quetiapine was well tolerated alone and in combination with divalproex, Dr. DelBello said.

Sedation (mostly mild and transient) was the most common adverse event, followed by dizziness and gastrointestinal upset. No patients discontinued therapy because of adverse events.

The poster was sponsored by AstraZeneca.

TORONTO – Quetiapine appears to improve symptoms of depression and suicidal ideation in adolescents with bipolar disorder, mood disorder, and those at familial risk of developing bipolar disorder, according to a poster presented at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

Dr. Melissa DelBello of the University of Cincinnati and her colleagues presented the results of three studies of the drug in bipolar adolescents aged 12–18 years.

Study 1 included 30 adolescents hospitalized with mixed or manic episodes.

The patients were randomized to divalproex or divalproex plus quetiapine (mean dose 423 mg/day) for 6 weeks.

Those in the combination group experienced a greater mean decrease in depression scores from baseline than did those in the divalproex-only group (from 50 to 24 vs. 50 to 34, respectively).

Study 2 included 50 patients hospitalized with bipolar I disorder (94% mixed, 6% manic episodes).

They were randomized to quetiapine (Seroquel) monotherapy (mean dose 417 mg/day) or divalproex monotherapy for 4 weeks.

Mean depression scores in the quetiapine group decreased from 52 to 25. Dr. DelBello did not analyze the divalproex response in this study.

Study 3 included 25 hospitalized adolescents with a mood disorder and with at least one parent with bipolar disorder.

The adolescents received quetiapine monotherapy (mean dose 447 mg/day) for 12 weeks. Mean depression scores decreased from 40 to 29.

In the three studies, 65 patients who took quetiapine alone had major depression. Overall, their mean suicidality score decreased from 3.0 to 1.5.

The suicidality score increased, however, in two of the patients, both of whom were taking quetiapine.

Quetiapine was well tolerated alone and in combination with divalproex, Dr. DelBello said.

Sedation (mostly mild and transient) was the most common adverse event, followed by dizziness and gastrointestinal upset. No patients discontinued therapy because of adverse events.

The poster was sponsored by AstraZeneca.

TORONTO – Quetiapine appears to improve symptoms of depression and suicidal ideation in adolescents with bipolar disorder, mood disorder, and those at familial risk of developing bipolar disorder, according to a poster presented at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

Dr. Melissa DelBello of the University of Cincinnati and her colleagues presented the results of three studies of the drug in bipolar adolescents aged 12–18 years.

Study 1 included 30 adolescents hospitalized with mixed or manic episodes.

The patients were randomized to divalproex or divalproex plus quetiapine (mean dose 423 mg/day) for 6 weeks.

Those in the combination group experienced a greater mean decrease in depression scores from baseline than did those in the divalproex-only group (from 50 to 24 vs. 50 to 34, respectively).

Study 2 included 50 patients hospitalized with bipolar I disorder (94% mixed, 6% manic episodes).

They were randomized to quetiapine (Seroquel) monotherapy (mean dose 417 mg/day) or divalproex monotherapy for 4 weeks.

Mean depression scores in the quetiapine group decreased from 52 to 25. Dr. DelBello did not analyze the divalproex response in this study.

Study 3 included 25 hospitalized adolescents with a mood disorder and with at least one parent with bipolar disorder.

The adolescents received quetiapine monotherapy (mean dose 447 mg/day) for 12 weeks. Mean depression scores decreased from 40 to 29.

In the three studies, 65 patients who took quetiapine alone had major depression. Overall, their mean suicidality score decreased from 3.0 to 1.5.

The suicidality score increased, however, in two of the patients, both of whom were taking quetiapine.

Quetiapine was well tolerated alone and in combination with divalproex, Dr. DelBello said.

Sedation (mostly mild and transient) was the most common adverse event, followed by dizziness and gastrointestinal upset. No patients discontinued therapy because of adverse events.

The poster was sponsored by AstraZeneca.

TORONTO – Many children with bipolar disorder experience a lengthy prodromal phase of clinically significant symptoms before their first manic episode; in almost 70% of these children, the prodrome begins with a drop in school functioning, often accompanied by racing thoughts, irritability, and anger, and can last for almost 1 year.

Recognizing such a prodrome could help facilitate an early intervention program for children who are at risk of developing bipolar disorder, Dr. Christoph Correll reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“The sufficient duration and severity of this prodrome enables the development of early identification and prevention programs,” wrote Dr. Correll, a psychiatrist at the Zucker Hillside Hospital, Glen Oaks, N.Y. However, “prospective studies are required to validate these findings and to test effective interventions.”

Dr. Correll characterized the onset of bipolar disorder in 51 patients by interviewing the patients and/or their parents with his newly created Bipolar Prodrome Symptoms Scale-Retrospective Version.

The questionnaire asks parents and patients to rate 39 putatively prodromal symptoms that can emerge before the occurrence of a syndromal manic or hypomanic episode.

The scale–an in-person structured interview with patient or parent alone–takes between 1 and 1.5 hours to complete. It was developed based on DSM-IV criteria for major depressive disorder and bipolar disorder, a review of the literature, input from experts in the areas of schizophrenia prodrome and bipolar disorder, and open questioning of young patients and their caregivers.

Dr. Correll also drew the symptoms that the scale assesses from several retrospective studies that have identified some possibly prodromal traits, including depressed mood or hopelessness, hyperactivity, mood swings, increased or decreased energy, irritability or anger dyscontrol, argumentativeness, decreased sleep, crying spells, inappropriate behaviors, and overtalkativeness.

The patients' mean age was 16 years; the mean age at first manic episode was 13 years.

The patients experienced a mean of 13 of the prodromal symptoms, which preceded the first full manic episode by nearly 1 year.

In more than half of the patients, the most commonly reported symptoms that were at least moderately severe were a drop in school functioning, irritability or anger, racing thoughts, mood swings, inattention, depressed mood, and anger outbursts or tantrums.

At least moderately severe symptoms of increased energy, psychomotor agitation, overtalkativeness, and social isolation occurred in more than 40% of patients.

The most common presenting symptoms were a drop in school functioning, mood swings, depressed mood, irritability or anger, social isolation, and racing thoughts.

About one in five patients reported presenting symptoms of oppositionality, anhedonia, being overly cheerful, psychomotor agitation, or inattention.

The lag between first manic episode and bipolar disorder diagnosis was about 20 months, but the lag between onset of prodromal symptoms and diagnosis was twice that long–a mean of 41 months.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration; 29% of patients experienced a slow onset with quick deterioration, while only 12% experienced a rapid onset of illness.

The newly developed scale will be useful not only in assessing a possible prodrome, but in research as well, Dr. Correll said in an interview.

“It can be used in future studies to determine different patterns of symptom onset and contributing factors to symptom onset, as well as to identify characteristics that may define a person who may be at ultrahigh risk for the development of bipolar disorder,” he said.

He is also working on a prospective version of the scale, which he hopes will be a valuable predictive tool. “We have already used the data from this study to develop a prospective version of the scale,” Dr. Correll said.

“We are now in the process of validating the scale and criteria that predict conversion to bipolar disorder in patients considered to be at clinical risk for the development of bipolar disorder,” he commented.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration. DR. CORRELL

TORONTO – Many children with bipolar disorder experience a lengthy prodromal phase of clinically significant symptoms before their first manic episode; in almost 70% of these children, the prodrome begins with a drop in school functioning, often accompanied by racing thoughts, irritability, and anger, and can last for almost 1 year.

Recognizing such a prodrome could help facilitate an early intervention program for children who are at risk of developing bipolar disorder, Dr. Christoph Correll reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“The sufficient duration and severity of this prodrome enables the development of early identification and prevention programs,” wrote Dr. Correll, a psychiatrist at the Zucker Hillside Hospital, Glen Oaks, N.Y. However, “prospective studies are required to validate these findings and to test effective interventions.”

Dr. Correll characterized the onset of bipolar disorder in 51 patients by interviewing the patients and/or their parents with his newly created Bipolar Prodrome Symptoms Scale-Retrospective Version.

The questionnaire asks parents and patients to rate 39 putatively prodromal symptoms that can emerge before the occurrence of a syndromal manic or hypomanic episode.

The scale–an in-person structured interview with patient or parent alone–takes between 1 and 1.5 hours to complete. It was developed based on DSM-IV criteria for major depressive disorder and bipolar disorder, a review of the literature, input from experts in the areas of schizophrenia prodrome and bipolar disorder, and open questioning of young patients and their caregivers.

Dr. Correll also drew the symptoms that the scale assesses from several retrospective studies that have identified some possibly prodromal traits, including depressed mood or hopelessness, hyperactivity, mood swings, increased or decreased energy, irritability or anger dyscontrol, argumentativeness, decreased sleep, crying spells, inappropriate behaviors, and overtalkativeness.

The patients' mean age was 16 years; the mean age at first manic episode was 13 years.

The patients experienced a mean of 13 of the prodromal symptoms, which preceded the first full manic episode by nearly 1 year.

In more than half of the patients, the most commonly reported symptoms that were at least moderately severe were a drop in school functioning, irritability or anger, racing thoughts, mood swings, inattention, depressed mood, and anger outbursts or tantrums.

At least moderately severe symptoms of increased energy, psychomotor agitation, overtalkativeness, and social isolation occurred in more than 40% of patients.

The most common presenting symptoms were a drop in school functioning, mood swings, depressed mood, irritability or anger, social isolation, and racing thoughts.

About one in five patients reported presenting symptoms of oppositionality, anhedonia, being overly cheerful, psychomotor agitation, or inattention.

The lag between first manic episode and bipolar disorder diagnosis was about 20 months, but the lag between onset of prodromal symptoms and diagnosis was twice that long–a mean of 41 months.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration; 29% of patients experienced a slow onset with quick deterioration, while only 12% experienced a rapid onset of illness.

The newly developed scale will be useful not only in assessing a possible prodrome, but in research as well, Dr. Correll said in an interview.

“It can be used in future studies to determine different patterns of symptom onset and contributing factors to symptom onset, as well as to identify characteristics that may define a person who may be at ultrahigh risk for the development of bipolar disorder,” he said.

He is also working on a prospective version of the scale, which he hopes will be a valuable predictive tool. “We have already used the data from this study to develop a prospective version of the scale,” Dr. Correll said.

“We are now in the process of validating the scale and criteria that predict conversion to bipolar disorder in patients considered to be at clinical risk for the development of bipolar disorder,” he commented.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration. DR. CORRELL

TORONTO – Many children with bipolar disorder experience a lengthy prodromal phase of clinically significant symptoms before their first manic episode; in almost 70% of these children, the prodrome begins with a drop in school functioning, often accompanied by racing thoughts, irritability, and anger, and can last for almost 1 year.

Recognizing such a prodrome could help facilitate an early intervention program for children who are at risk of developing bipolar disorder, Dr. Christoph Correll reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“The sufficient duration and severity of this prodrome enables the development of early identification and prevention programs,” wrote Dr. Correll, a psychiatrist at the Zucker Hillside Hospital, Glen Oaks, N.Y. However, “prospective studies are required to validate these findings and to test effective interventions.”

Dr. Correll characterized the onset of bipolar disorder in 51 patients by interviewing the patients and/or their parents with his newly created Bipolar Prodrome Symptoms Scale-Retrospective Version.

The questionnaire asks parents and patients to rate 39 putatively prodromal symptoms that can emerge before the occurrence of a syndromal manic or hypomanic episode.

The scale–an in-person structured interview with patient or parent alone–takes between 1 and 1.5 hours to complete. It was developed based on DSM-IV criteria for major depressive disorder and bipolar disorder, a review of the literature, input from experts in the areas of schizophrenia prodrome and bipolar disorder, and open questioning of young patients and their caregivers.

Dr. Correll also drew the symptoms that the scale assesses from several retrospective studies that have identified some possibly prodromal traits, including depressed mood or hopelessness, hyperactivity, mood swings, increased or decreased energy, irritability or anger dyscontrol, argumentativeness, decreased sleep, crying spells, inappropriate behaviors, and overtalkativeness.

The patients' mean age was 16 years; the mean age at first manic episode was 13 years.

The patients experienced a mean of 13 of the prodromal symptoms, which preceded the first full manic episode by nearly 1 year.

In more than half of the patients, the most commonly reported symptoms that were at least moderately severe were a drop in school functioning, irritability or anger, racing thoughts, mood swings, inattention, depressed mood, and anger outbursts or tantrums.

At least moderately severe symptoms of increased energy, psychomotor agitation, overtalkativeness, and social isolation occurred in more than 40% of patients.

The most common presenting symptoms were a drop in school functioning, mood swings, depressed mood, irritability or anger, social isolation, and racing thoughts.

About one in five patients reported presenting symptoms of oppositionality, anhedonia, being overly cheerful, psychomotor agitation, or inattention.

The lag between first manic episode and bipolar disorder diagnosis was about 20 months, but the lag between onset of prodromal symptoms and diagnosis was twice that long–a mean of 41 months.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration; 29% of patients experienced a slow onset with quick deterioration, while only 12% experienced a rapid onset of illness.

The newly developed scale will be useful not only in assessing a possible prodrome, but in research as well, Dr. Correll said in an interview.

“It can be used in future studies to determine different patterns of symptom onset and contributing factors to symptom onset, as well as to identify characteristics that may define a person who may be at ultrahigh risk for the development of bipolar disorder,” he said.

He is also working on a prospective version of the scale, which he hopes will be a valuable predictive tool. “We have already used the data from this study to develop a prospective version of the scale,” Dr. Correll said.

“We are now in the process of validating the scale and criteria that predict conversion to bipolar disorder in patients considered to be at clinical risk for the development of bipolar disorder,” he commented.

In most patients (59%), the prodromal onset was slow and marked by gradual deterioration. DR. CORRELL

TORONTO – A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that the skills taught in the Resourceful Adolescents Project will have a positive impact on other psychological problems that the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” noted Dr. Wolfe, who is with the Children's Hospital of the University of Western Ontario in London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

The Resourceful Adolescent Project (RAP), which was first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

The program's classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI).

On the Harter's Self-Perception Profile for Children, the girls' average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1), Dr. Wolfe reported

On the Harter's Self-Perception Profile for Children, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results: “It's relatively small sample for a prevention program, and we would like to examine other indices of change–parent report, for example.”

She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

TORONTO – A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that the skills taught in the Resourceful Adolescents Project will have a positive impact on other psychological problems that the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” noted Dr. Wolfe, who is with the Children's Hospital of the University of Western Ontario in London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

The Resourceful Adolescent Project (RAP), which was first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

The program's classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI).

On the Harter's Self-Perception Profile for Children, the girls' average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1), Dr. Wolfe reported

On the Harter's Self-Perception Profile for Children, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results: “It's relatively small sample for a prevention program, and we would like to examine other indices of change–parent report, for example.”

She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

TORONTO – A pilot program aimed at building resiliency and coping skills in teenage girls appears to decrease symptoms of depression and increase self-esteem in those at risk for major depressive disorder.

Researchers also hope that the skills taught in the Resourceful Adolescents Project will have a positive impact on other psychological problems that the teens might face, such as eating disorders, substance abuse, and rule violations, Vicky Veitch Wolfe, Ph.D., said at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.

“We see a sharp increase in mental health problems in adolescents,” noted Dr. Wolfe, who is with the Children's Hospital of the University of Western Ontario in London. “Up to 10% of high school girls develop depression, and 24% of girls report at least one episode of depression during their adolescence. This program is designed to help girls transition between middle school and high school, where we start to see the increase in depression.”

The Resourceful Adolescent Project (RAP), which was first developed in Australia and New Zealand, is administered as part of a school's health curriculum. In Dr. Wolfe's pilot project, the program consisted of 10 70-minute sessions taught by a RAP psychologist and other mental health professionals.

The program's classroom topics included recognizing and regulating bodily stress; correcting negative self-talk; building personal strengths, problem solving, and conflict resolution skills; developing a strong social support network; using humor as a coping mechanism; and effective goal setting.

In addition to classroom activities and discussion, the students used a specially designed workbook and received regular homework assignments. Those activities were graded.

The program was instituted in 12 schools in one Ontario county; 807 ninth-grade girls were enrolled, with half receiving the intervention program and half receiving their normal health education class. Dr. Wolfe presented an analysis of the program's effects on 110 girls who were considered at high risk of depression.

At baseline, the girls had an average score of 22 on the Children's Depression Index (CDI).

On the Harter's Self-Perception Profile for Children, the girls' average baseline score was about 11 for self, 14.5 for friends, 14 for job, and 9 for appearance.

After the program, the intervention group had significantly decreased their total CDI scores from baseline (22–16.5) as well as their individual scores on mood (5.6–4.0), anhedonia (6.7–4.9), and negative self-esteem (4.5–3.1).

Total CDI scores decreased to a lesser extent in the control group (22–20.5), as did scores for mood (5.5–4.9), anhedonia (6.7–6.1), and negative self-esteem (4.3–4.1), Dr. Wolfe reported

On the Harter's Self-Perception Profile for Children, the intervention group made significant improvements in all areas: self (10.5–12.7), friends (14.3–15.4), job (13.8–15.5), and appearance (8.9–10.6). No significant changes were found in the control group.

A mechanism of change score identified the social domain as the area of greatest change, Dr. Wolfe said. “We saw improved coping and improved interpersonal relationships, particularly with parents,” she said.

Dr. Wolfe cautioned against overinterpretation of her results: “It's relatively small sample for a prevention program, and we would like to examine other indices of change–parent report, for example.”

She will also be conducting longer-term analyses of the effects in the entire group, with follow-up at 6, 12, and 18 months.

KISSIMMEE, FLA. — Stroke risk is highest in the first years after receiving a diagnosis of type 2 diabetes, with a 17-fold higher risk for patients aged 18–34 years old, researchers reported at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk,” he said at the meeting sponsored by the American Stroke Association.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes to those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), likelier to be black (25% vs. 15%), and likelier to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those under age 55. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have focused on glycemic control and the prevention of microvascular disease, said Dr. Kissela.

“Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added. “In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck,” he said.

KISSIMMEE, FLA. — Stroke risk is highest in the first years after receiving a diagnosis of type 2 diabetes, with a 17-fold higher risk for patients aged 18–34 years old, researchers reported at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk,” he said at the meeting sponsored by the American Stroke Association.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes to those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), likelier to be black (25% vs. 15%), and likelier to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those under age 55. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have focused on glycemic control and the prevention of microvascular disease, said Dr. Kissela.

“Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added. “In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck,” he said.

KISSIMMEE, FLA. — Stroke risk is highest in the first years after receiving a diagnosis of type 2 diabetes, with a 17-fold higher risk for patients aged 18–34 years old, researchers reported at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk,” he said at the meeting sponsored by the American Stroke Association.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes to those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), likelier to be black (25% vs. 15%), and likelier to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those under age 55. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have focused on glycemic control and the prevention of microvascular disease, said Dr. Kissela.

“Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added. “In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck,” he said.

CAMBRIDGE, MD. — An early resection with negative tumor margins remains the only hope for long-term survival in patients with cholangiocarcinoma, Dr. Richard Schulick said at a hepatobiliary update sponsored by Johns Hopkins University.

Worldwide, long-term survival in this disease is only about 3.5%, said Dr. Schulick. But in the United States, carefully selected patients whose early tumors are resected with negative margins can potentially have long-term survival, he said.

Patients typically present with right upper quadrant pain, which may be misdiagnosed as cholecystitis, stones, or pancreatic or bile duct cancer. The common cancer symptoms of weight loss and nausea are often present. Neither carcinoembryonic antigen nor carbohydrate antigen 19–9 are sensitive enough to be used exclusively for diagnosis, “although they can be useful in tracking recurrence,” said Dr. Schulick of Johns Hopkins University, Baltimore.

When assessing resectability, Dr. Schulick considers the biliary, vascular, and parenchymal systems separately. “The questions are, 'Can I preserve a portion of the biliary tree, the vascular in- and outflow of that section of the liver, and will there be enough liver left for the patient to survive?'” he said.

He presented survival data from 564 cases of cholangiocarcinoma treated at Johns Hopkins from 1973 to 2004.

Intrahepatic tumors occurred in 44 patients and were treated with hepatic resection, with or without lymph node removal. These patients had the best long-term survival rates. In the 20 whose tumors had negative margins, 5-year survival was 68%. This dropped to 33% for the nine patients whose tumors had positive margins. Fifteen patients received palliative care; their median survival was only 7 months.

Perihilar tumors occurred in 281 patients. These tumors, located in the hepatic duct bifurcation, are treated by excising the extrahepatic biliary tree, with or without lymph nodes. A hepatic resection and/or caudate lobectomy might be required. Operative mortality is relatively high: 4%–10%, Dr. Schulick said. “This is a reflection of the aggressiveness of the operation.”

Long-term survival was not as good in this group, Dr. Schulick said. Of the 52 patients with margin-negative tumors, only 27% were alive at 5 years. Only 8% of the 121 with margin-positive tumors were alive at 5 years. Most of the patients (108) were not candidates for surgery and received palliative care; their median survival time was 9 months.

Distal tumors, located in the distal common bile duct, occurred in 239 patients. These tumors were treated by pancreaticoduodenectomy or excision of the extrahepatic biliary tree.

Again, long-term survival was not good. Of the 187 patients with margin-negative tumors, 21% were alive at 5 years. Only 6% of the 42 with margin-positive tumors were alive at 5 years. Ten patients received palliative care; their median survival time was 13 months.

CAMBRIDGE, MD. — An early resection with negative tumor margins remains the only hope for long-term survival in patients with cholangiocarcinoma, Dr. Richard Schulick said at a hepatobiliary update sponsored by Johns Hopkins University.

Worldwide, long-term survival in this disease is only about 3.5%, said Dr. Schulick. But in the United States, carefully selected patients whose early tumors are resected with negative margins can potentially have long-term survival, he said.

Patients typically present with right upper quadrant pain, which may be misdiagnosed as cholecystitis, stones, or pancreatic or bile duct cancer. The common cancer symptoms of weight loss and nausea are often present. Neither carcinoembryonic antigen nor carbohydrate antigen 19–9 are sensitive enough to be used exclusively for diagnosis, “although they can be useful in tracking recurrence,” said Dr. Schulick of Johns Hopkins University, Baltimore.

When assessing resectability, Dr. Schulick considers the biliary, vascular, and parenchymal systems separately. “The questions are, 'Can I preserve a portion of the biliary tree, the vascular in- and outflow of that section of the liver, and will there be enough liver left for the patient to survive?'” he said.

He presented survival data from 564 cases of cholangiocarcinoma treated at Johns Hopkins from 1973 to 2004.

Intrahepatic tumors occurred in 44 patients and were treated with hepatic resection, with or without lymph node removal. These patients had the best long-term survival rates. In the 20 whose tumors had negative margins, 5-year survival was 68%. This dropped to 33% for the nine patients whose tumors had positive margins. Fifteen patients received palliative care; their median survival was only 7 months.

Perihilar tumors occurred in 281 patients. These tumors, located in the hepatic duct bifurcation, are treated by excising the extrahepatic biliary tree, with or without lymph nodes. A hepatic resection and/or caudate lobectomy might be required. Operative mortality is relatively high: 4%–10%, Dr. Schulick said. “This is a reflection of the aggressiveness of the operation.”

Long-term survival was not as good in this group, Dr. Schulick said. Of the 52 patients with margin-negative tumors, only 27% were alive at 5 years. Only 8% of the 121 with margin-positive tumors were alive at 5 years. Most of the patients (108) were not candidates for surgery and received palliative care; their median survival time was 9 months.

Distal tumors, located in the distal common bile duct, occurred in 239 patients. These tumors were treated by pancreaticoduodenectomy or excision of the extrahepatic biliary tree.

Again, long-term survival was not good. Of the 187 patients with margin-negative tumors, 21% were alive at 5 years. Only 6% of the 42 with margin-positive tumors were alive at 5 years. Ten patients received palliative care; their median survival time was 13 months.

CAMBRIDGE, MD. — An early resection with negative tumor margins remains the only hope for long-term survival in patients with cholangiocarcinoma, Dr. Richard Schulick said at a hepatobiliary update sponsored by Johns Hopkins University.

Worldwide, long-term survival in this disease is only about 3.5%, said Dr. Schulick. But in the United States, carefully selected patients whose early tumors are resected with negative margins can potentially have long-term survival, he said.

Patients typically present with right upper quadrant pain, which may be misdiagnosed as cholecystitis, stones, or pancreatic or bile duct cancer. The common cancer symptoms of weight loss and nausea are often present. Neither carcinoembryonic antigen nor carbohydrate antigen 19–9 are sensitive enough to be used exclusively for diagnosis, “although they can be useful in tracking recurrence,” said Dr. Schulick of Johns Hopkins University, Baltimore.

When assessing resectability, Dr. Schulick considers the biliary, vascular, and parenchymal systems separately. “The questions are, 'Can I preserve a portion of the biliary tree, the vascular in- and outflow of that section of the liver, and will there be enough liver left for the patient to survive?'” he said.

He presented survival data from 564 cases of cholangiocarcinoma treated at Johns Hopkins from 1973 to 2004.

Intrahepatic tumors occurred in 44 patients and were treated with hepatic resection, with or without lymph node removal. These patients had the best long-term survival rates. In the 20 whose tumors had negative margins, 5-year survival was 68%. This dropped to 33% for the nine patients whose tumors had positive margins. Fifteen patients received palliative care; their median survival was only 7 months.

Perihilar tumors occurred in 281 patients. These tumors, located in the hepatic duct bifurcation, are treated by excising the extrahepatic biliary tree, with or without lymph nodes. A hepatic resection and/or caudate lobectomy might be required. Operative mortality is relatively high: 4%–10%, Dr. Schulick said. “This is a reflection of the aggressiveness of the operation.”

Long-term survival was not as good in this group, Dr. Schulick said. Of the 52 patients with margin-negative tumors, only 27% were alive at 5 years. Only 8% of the 121 with margin-positive tumors were alive at 5 years. Most of the patients (108) were not candidates for surgery and received palliative care; their median survival time was 9 months.

Distal tumors, located in the distal common bile duct, occurred in 239 patients. These tumors were treated by pancreaticoduodenectomy or excision of the extrahepatic biliary tree.

Again, long-term survival was not good. Of the 187 patients with margin-negative tumors, 21% were alive at 5 years. Only 6% of the 42 with margin-positive tumors were alive at 5 years. Ten patients received palliative care; their median survival time was 13 months.

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

The Food and Drug Administration has approved new labeling that relaxes the liver enzyme monitoring recommendations for tolcapone, an adjunctive treatment for Parkinson's disease, according to the drug's manufacturer.

The new label recommends monitoring serum glutamic-pyruvic transaminase (SGPT/ALT) and serum glutamic-oxaloacetic transaminase (SGOT/AST) at baseline, then every 2–4 weeks for the first 6 months. After that, periodic monitoring is recommended as the prescribing physician deems clinically relevant.

The drug was approved as Tasmar in January 1998 for adjunctive use in patients whose Parkinson's symptoms are not adequately controlled despite being on adequate doses of levodopa/carbidopa, according to the FDA. By October of that year, FDA had received reports of three cases of fatal fulminant liver failure; the agency said many more cases might have gone unreported. The reports prompted a black box warning on the drug label, citing an increased risk for liver failure of up to 100 times above the background population. The warning recommended liver enzyme monitoring every 2 weeks for the first year of therapy, every 4 weeks for the next 6 months, and then every 8 weeks thereafter. It also required patients to sign a consent form acknowledging that they understood the increased risk of liver failure associated with the drug.

However, based on a data analysis by Valeant Pharmaceuticals International, which makes the drug, FDA has concluded that the risk of liver failure is probably lower than initially estimated. The analysis included more than 40,000 patient years of prescription data and laboratory test data from more than 3,400 patients who participated in tolcapone clinical trials.

“Recent data suggest that hepatic dysfunction associated with Tasmar is rare and can be addressed with less restrictive monitoring,” Dr. C. Warren Olanow, professor and chair of neurology at Mount Sinai School of Medicine, New York, said in a statement on the company's Web site (www.valeant.com

The new label information should show up soon on the drug's packaging, said Dan Springer, a spokesman for Valeant.

The Food and Drug Administration has approved new labeling that relaxes the liver enzyme monitoring recommendations for tolcapone, an adjunctive treatment for Parkinson's disease, according to the drug's manufacturer.

The new label recommends monitoring serum glutamic-pyruvic transaminase (SGPT/ALT) and serum glutamic-oxaloacetic transaminase (SGOT/AST) at baseline, then every 2–4 weeks for the first 6 months. After that, periodic monitoring is recommended as the prescribing physician deems clinically relevant.

The drug was approved as Tasmar in January 1998 for adjunctive use in patients whose Parkinson's symptoms are not adequately controlled despite being on adequate doses of levodopa/carbidopa, according to the FDA. By October of that year, FDA had received reports of three cases of fatal fulminant liver failure; the agency said many more cases might have gone unreported. The reports prompted a black box warning on the drug label, citing an increased risk for liver failure of up to 100 times above the background population. The warning recommended liver enzyme monitoring every 2 weeks for the first year of therapy, every 4 weeks for the next 6 months, and then every 8 weeks thereafter. It also required patients to sign a consent form acknowledging that they understood the increased risk of liver failure associated with the drug.

However, based on a data analysis by Valeant Pharmaceuticals International, which makes the drug, FDA has concluded that the risk of liver failure is probably lower than initially estimated. The analysis included more than 40,000 patient years of prescription data and laboratory test data from more than 3,400 patients who participated in tolcapone clinical trials.

“Recent data suggest that hepatic dysfunction associated with Tasmar is rare and can be addressed with less restrictive monitoring,” Dr. C. Warren Olanow, professor and chair of neurology at Mount Sinai School of Medicine, New York, said in a statement on the company's Web site (www.valeant.com

The new label information should show up soon on the drug's packaging, said Dan Springer, a spokesman for Valeant.

The Food and Drug Administration has approved new labeling that relaxes the liver enzyme monitoring recommendations for tolcapone, an adjunctive treatment for Parkinson's disease, according to the drug's manufacturer.

The new label recommends monitoring serum glutamic-pyruvic transaminase (SGPT/ALT) and serum glutamic-oxaloacetic transaminase (SGOT/AST) at baseline, then every 2–4 weeks for the first 6 months. After that, periodic monitoring is recommended as the prescribing physician deems clinically relevant.

The drug was approved as Tasmar in January 1998 for adjunctive use in patients whose Parkinson's symptoms are not adequately controlled despite being on adequate doses of levodopa/carbidopa, according to the FDA. By October of that year, FDA had received reports of three cases of fatal fulminant liver failure; the agency said many more cases might have gone unreported. The reports prompted a black box warning on the drug label, citing an increased risk for liver failure of up to 100 times above the background population. The warning recommended liver enzyme monitoring every 2 weeks for the first year of therapy, every 4 weeks for the next 6 months, and then every 8 weeks thereafter. It also required patients to sign a consent form acknowledging that they understood the increased risk of liver failure associated with the drug.

However, based on a data analysis by Valeant Pharmaceuticals International, which makes the drug, FDA has concluded that the risk of liver failure is probably lower than initially estimated. The analysis included more than 40,000 patient years of prescription data and laboratory test data from more than 3,400 patients who participated in tolcapone clinical trials.

“Recent data suggest that hepatic dysfunction associated with Tasmar is rare and can be addressed with less restrictive monitoring,” Dr. C. Warren Olanow, professor and chair of neurology at Mount Sinai School of Medicine, New York, said in a statement on the company's Web site (www.valeant.com

The new label information should show up soon on the drug's packaging, said Dan Springer, a spokesman for Valeant.

Rheumatic Fever's Decline

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues.

This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children in Chicago and nationwide during 2000–2004 (CID 2006;42:441–7).

Several rheumatic types of group A streptococcus were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period.

In contrast, the proportion of several nonrheumatogenic types increased significantly between the study periods, from about 5% to nearly 28% of isolates both in Chicago and nationwide.

Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Predictive Model of Lyme Meningitis

Three conditions—a long-lasting head-ache, the presence of cranial neuritis, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients. Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% among the LM patients vs. 58% among the AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

However, high levels of CSF mononuclear cells are not specific to LM alone, and this finding must be supported by longer-lasting headaches and the presence of cranial neuritis for an LM diagnosis, the researchers noted. All three conditions made statistically significant contributions to the prediction model.

Based on a regression analysis in which all three conditions were considered, the odds ratio for LM for each variable was 2.9 for a patient with a headache lasting 14 days, 3.4 for a patient with 90% CSF mononuclear cells, and 16.9 for a patient with cranial neuritis.

Flu Shots a Must in Kids With NNMD

Flu shots are de rigueur for children with neurologic and neuromuscular diseases given their high risk of influenza-related respiratory failure.

“Children with pulmonary disease, cardiac disease, or NNMD [neurologic and neuromuscular disease] had approximately a 10% probability of respiratory failure” during a hospitalization for influenza, Dr. Ron Keren and colleagues reported. “Having two of the three chronic conditions increased the probability another three- to fourfold” (JAMA 2005;294:2188–94).

Dr. Keren, of the Children's Hospital of Philadelphia, and associates examined rates of respiratory failure in 745 children and adolescents (aged 21 years and younger) in 2000–2004. Eighty-nine (12%) had an NNMD, most commonly cerebral palsy (40%), seizure disorders (42%), and hydrocephalus/cerebrospinal fluid shunt (30%).

During the study period, 32 children developed respiratory failure; 14 of those had an NNMD, a sixfold increased risk compared with those with no chronic health problem. This risk was higher than that associated with pulmonary disease (OR 5.0) or cardiac disease (OR 4.0), both of which are accepted indications for an annual childhood influenza vaccine.

Rheumatic Fever's Decline

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues.

This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children in Chicago and nationwide during 2000–2004 (CID 2006;42:441–7).

Several rheumatic types of group A streptococcus were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period.

In contrast, the proportion of several nonrheumatogenic types increased significantly between the study periods, from about 5% to nearly 28% of isolates both in Chicago and nationwide.

Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Predictive Model of Lyme Meningitis

Three conditions—a long-lasting head-ache, the presence of cranial neuritis, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients. Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% among the LM patients vs. 58% among the AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

However, high levels of CSF mononuclear cells are not specific to LM alone, and this finding must be supported by longer-lasting headaches and the presence of cranial neuritis for an LM diagnosis, the researchers noted. All three conditions made statistically significant contributions to the prediction model.

Based on a regression analysis in which all three conditions were considered, the odds ratio for LM for each variable was 2.9 for a patient with a headache lasting 14 days, 3.4 for a patient with 90% CSF mononuclear cells, and 16.9 for a patient with cranial neuritis.

Flu Shots a Must in Kids With NNMD

Flu shots are de rigueur for children with neurologic and neuromuscular diseases given their high risk of influenza-related respiratory failure.

“Children with pulmonary disease, cardiac disease, or NNMD [neurologic and neuromuscular disease] had approximately a 10% probability of respiratory failure” during a hospitalization for influenza, Dr. Ron Keren and colleagues reported. “Having two of the three chronic conditions increased the probability another three- to fourfold” (JAMA 2005;294:2188–94).

Dr. Keren, of the Children's Hospital of Philadelphia, and associates examined rates of respiratory failure in 745 children and adolescents (aged 21 years and younger) in 2000–2004. Eighty-nine (12%) had an NNMD, most commonly cerebral palsy (40%), seizure disorders (42%), and hydrocephalus/cerebrospinal fluid shunt (30%).

During the study period, 32 children developed respiratory failure; 14 of those had an NNMD, a sixfold increased risk compared with those with no chronic health problem. This risk was higher than that associated with pulmonary disease (OR 5.0) or cardiac disease (OR 4.0), both of which are accepted indications for an annual childhood influenza vaccine.

Rheumatic Fever's Decline

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues.

This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children in Chicago and nationwide during 2000–2004 (CID 2006;42:441–7).

Several rheumatic types of group A streptococcus were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period.

In contrast, the proportion of several nonrheumatogenic types increased significantly between the study periods, from about 5% to nearly 28% of isolates both in Chicago and nationwide.

Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Predictive Model of Lyme Meningitis

Three conditions—a long-lasting head-ache, the presence of cranial neuritis, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients. Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% among the LM patients vs. 58% among the AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

However, high levels of CSF mononuclear cells are not specific to LM alone, and this finding must be supported by longer-lasting headaches and the presence of cranial neuritis for an LM diagnosis, the researchers noted. All three conditions made statistically significant contributions to the prediction model.

Based on a regression analysis in which all three conditions were considered, the odds ratio for LM for each variable was 2.9 for a patient with a headache lasting 14 days, 3.4 for a patient with 90% CSF mononuclear cells, and 16.9 for a patient with cranial neuritis.

Flu Shots a Must in Kids With NNMD

Flu shots are de rigueur for children with neurologic and neuromuscular diseases given their high risk of influenza-related respiratory failure.

“Children with pulmonary disease, cardiac disease, or NNMD [neurologic and neuromuscular disease] had approximately a 10% probability of respiratory failure” during a hospitalization for influenza, Dr. Ron Keren and colleagues reported. “Having two of the three chronic conditions increased the probability another three- to fourfold” (JAMA 2005;294:2188–94).

Dr. Keren, of the Children's Hospital of Philadelphia, and associates examined rates of respiratory failure in 745 children and adolescents (aged 21 years and younger) in 2000–2004. Eighty-nine (12%) had an NNMD, most commonly cerebral palsy (40%), seizure disorders (42%), and hydrocephalus/cerebrospinal fluid shunt (30%).

During the study period, 32 children developed respiratory failure; 14 of those had an NNMD, a sixfold increased risk compared with those with no chronic health problem. This risk was higher than that associated with pulmonary disease (OR 5.0) or cardiac disease (OR 4.0), both of which are accepted indications for an annual childhood influenza vaccine.

KISSIMMEE, FLA. — Diabetic patients face up to a 17-fold increased risk of stroke over the general population, and that risk is especially high in the first few years after their diabetes diagnosis, researchers said at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk. It's not something to put on the back burner and worry about decades from now,” he said.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

“The high rate of stroke in these younger patients shows that the effects of atherosclerosis are already established by the time they receive a diabetes diagnosis,” Dr. Jeerakathil said at the meeting sponsored by the American Stroke Association.

The hyperglycemia of diabetes probably contributes to the acceleration of atherosclerosis, but these patients also have other cardiovascular risk factors, including obesity, high triglycerides, and hypertension,” he said.

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes with the rate in those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), more likely to be black (25% vs. 15%), and more likely to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those younger than 55 years. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have always focused on glycemic control and the prevention of microvascular disease, Dr. Kissela said. “Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control. It's crucial.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added.

“In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck, but they are still not being adequately treated for hypertension,” he said.

'There is a real up-front risk. It's not something to put on the back burner and worry about decades from now.' DR. JEERAKATHIL

KISSIMMEE, FLA. — Diabetic patients face up to a 17-fold increased risk of stroke over the general population, and that risk is especially high in the first few years after their diabetes diagnosis, researchers said at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk. It's not something to put on the back burner and worry about decades from now,” he said.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

“The high rate of stroke in these younger patients shows that the effects of atherosclerosis are already established by the time they receive a diabetes diagnosis,” Dr. Jeerakathil said at the meeting sponsored by the American Stroke Association.

The hyperglycemia of diabetes probably contributes to the acceleration of atherosclerosis, but these patients also have other cardiovascular risk factors, including obesity, high triglycerides, and hypertension,” he said.

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes with the rate in those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), more likely to be black (25% vs. 15%), and more likely to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those younger than 55 years. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have always focused on glycemic control and the prevention of microvascular disease, Dr. Kissela said. “Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control. It's crucial.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added.

“In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck, but they are still not being adequately treated for hypertension,” he said.

'There is a real up-front risk. It's not something to put on the back burner and worry about decades from now.' DR. JEERAKATHIL

KISSIMMEE, FLA. — Diabetic patients face up to a 17-fold increased risk of stroke over the general population, and that risk is especially high in the first few years after their diabetes diagnosis, researchers said at the 31st International Stroke Conference.

The findings underscore the importance of early and aggressive management of cardiovascular risk factors in diabetic patients, especially the triumvirate of obesity, hypertension, and high triglyceride levels that constitute metabolic syndrome, said Dr. Thomas J. Jeerakathil of the University of Alberta, Edmonton.

“This should be a real wake-up call that cardiovascular risk factors in diabetics need to be tackled from the very beginning. There is a real up-front risk. It's not something to put on the back burner and worry about decades from now,” he said.

Both Dr. Jeerakathil and Dr. Brett M. Kissela of the University of Cincinnati undertook population-based epidemiologic studies of stroke in people with diabetes.

Dr. Jeerakathil's study included 12,272 patients in Saskatchewan who received a new prescription for oral hypoglycemic medication in 1991–1996, indicating newly diagnosed diabetes. The patients' average age was 64 years, and the average follow-up was 5 years.

During that time, 9% experienced a hospital admission for stroke and 22% of the entire cohort died. The rate of stroke was 1,025/100,000 person-years—double the rate seen in the general population (499/100,000 person-years).

“The high rate of stroke in these younger patients shows that the effects of atherosclerosis are already established by the time they receive a diabetes diagnosis,” Dr. Jeerakathil said at the meeting sponsored by the American Stroke Association.

The hyperglycemia of diabetes probably contributes to the acceleration of atherosclerosis, but these patients also have other cardiovascular risk factors, including obesity, high triglycerides, and hypertension,” he said.

Dr. Kissela's study also concluded that strokes were occurring earlier in diabetic patients than in nondiabetic patients.

He used a large Ohio medical database to compare the incidence of ischemic stroke in those with diabetes with the rate in those without diabetes. Of 2,432 patients who had strokes in 1999, 33% had a history of diabetes. Patients with diabetes and stroke were younger (70 vs. 73 years), more likely to be black (25% vs. 15%), and more likely to have a history of hypertension (82% vs. 66%), high cholesterol levels (31% vs. 18%), and myocardial infarction (19% vs. 12%).

In both whites and blacks with diabetes, the increased risk of stroke was highest in those younger than 55 years. White diabetics aged 18–34 had a 17-fold increase over the general population. The risk ratio was 8 in those aged 35–44, and 6 in those aged 45–54. For blacks, the increased risk was again highest for the youngest patients (8.5-fold increase). For those aged 35–44, the risk ratio was 7.5, and it was doubled for those aged 45–54.

The increased risk of stroke in young diabetics, coupled with the increased incidence of metabolic syndrome signs, should be a red flag for physicians who have always focused on glycemic control and the prevention of microvascular disease, Dr. Kissela said. “Glycemic control is important, but it's not enough. These patients are at great risk and need to be aggressively managed with weight control, blood pressure control, and lipid control. It's crucial.”

Previous studies have shown that diabetes patients benefit even more than the general population from hypertension control, Dr. Jeerakathil added.

“In the average population, if you lower blood pressure by 10 points, you lower the risk of stroke by 40%. But in diabetics, the same 10 points will lower the risk of stroke by 60%. They get more bang for the buck, but they are still not being adequately treated for hypertension,” he said.

'There is a real up-front risk. It's not something to put on the back burner and worry about decades from now.' DR. JEERAKATHIL