Patrice Wendling

CHICAGO — Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first-aid, specialized school-based interventions, and specialized community-based services.

“It wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre—the fourth deadliest school shooting in U.S. history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're going to retraumatize. That did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University.

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure—meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest in those with no exposure (3.4%). In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%).

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and her associates concluded.

The study also shows that distress is present months after tragic events. This is important because funding for most school-based recovery programs is limited to 12 months after a disaster, Dr. Brymer explained.

“Recovery programs in schools stop after their funding is over, so if you still have kids significantly impaired by a disaster, some kids aren't getting the services that they need,” she said in an interview. “We need to be advocating that there are programs and resources available longer term.”

Dr. Brymer disclosed no relevant conflicts of interest.

CHICAGO — Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first-aid, specialized school-based interventions, and specialized community-based services.

“It wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre—the fourth deadliest school shooting in U.S. history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're going to retraumatize. That did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University.

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure—meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest in those with no exposure (3.4%). In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%).

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and her associates concluded.

The study also shows that distress is present months after tragic events. This is important because funding for most school-based recovery programs is limited to 12 months after a disaster, Dr. Brymer explained.

“Recovery programs in schools stop after their funding is over, so if you still have kids significantly impaired by a disaster, some kids aren't getting the services that they need,” she said in an interview. “We need to be advocating that there are programs and resources available longer term.”

Dr. Brymer disclosed no relevant conflicts of interest.

CHICAGO — Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first-aid, specialized school-based interventions, and specialized community-based services.

“It wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre—the fourth deadliest school shooting in U.S. history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're going to retraumatize. That did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University.

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure—meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest in those with no exposure (3.4%). In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%).

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and her associates concluded.

The study also shows that distress is present months after tragic events. This is important because funding for most school-based recovery programs is limited to 12 months after a disaster, Dr. Brymer explained.

“Recovery programs in schools stop after their funding is over, so if you still have kids significantly impaired by a disaster, some kids aren't getting the services that they need,” she said in an interview. “We need to be advocating that there are programs and resources available longer term.”

Dr. Brymer disclosed no relevant conflicts of interest.

CHICAGO — Age less than 2 months and male gender were significant independent predictors of relapse in children after ED treatment for bronchiolitis, according to a secondary analysis of a prospective, observational multicenter cohort of 1,459 patients.

Almost one in five children relapsed within 2 weeks of discharge from the ED—a number comparable with relapse rates observed in children with asthma, Dr. Muhammad Waseem and colleagues reported at the annual meeting of the American College of Emergency Physicians.

Bronchiolitis is a common condition in children younger than 2 years—yet there is little, if any, evidence for physicians and parents about which children will have a worsening of their disease after being discharged home from the ED, Dr. Waseem said.

Children younger than 2 years (median 6 months) were enrolled at 30 sites in 15 states during two consecutive bronchiolitis seasons: Dec. 1, 2004, through March 31, 2005, and Dec. 1, 2005, through March 31, 2006. A total of 58% of the Multicenter Airway Research Collaboration cohort's children were male; 38% of patients were white, 31% were black, 26% were Hispanic, and 4% were categorized as other.

Among the 1,243 (85%) patients for whom telephone follow-up was completed at 2 weeks, 722 (58%) were discharged home and met the analysis criteria.

Among the 717 children with relapse data, 121 (17%) had a post-ED relapse event defined as any urgent visit to an ED or clinic for worsening of bronchiolitis during the 2-week follow-up period.

Using a more restrictive definition of worsening of bronchiolitis that included changing the child's medication or hospital admission, 80 children (11%) relapsed, the researchers reported.

Children who had a post-ED relapse event were significantly more likely than those who did not to be younger than 2 months (11% vs. 6%) and male (70% vs. 57%), said Dr. Waseem, an attending physician in emergency medicine at Lincoln Medical and Mental Health Center, Bronx, N.Y., and an associate professor in emergency medicine at Cornell University Medical School, New York.

The study was supported by the Thrasher Research Fund and a data analysis grant from Merck & Co.

Coauthors Dr. Jonathan M. Mansbach and Dr. Carlos A. Camargo disclosed having received investigator-initiated research grants from AstraZeneca PLC, MedImmune Inc., and Merck.

CHICAGO — Age less than 2 months and male gender were significant independent predictors of relapse in children after ED treatment for bronchiolitis, according to a secondary analysis of a prospective, observational multicenter cohort of 1,459 patients.

Almost one in five children relapsed within 2 weeks of discharge from the ED—a number comparable with relapse rates observed in children with asthma, Dr. Muhammad Waseem and colleagues reported at the annual meeting of the American College of Emergency Physicians.

Bronchiolitis is a common condition in children younger than 2 years—yet there is little, if any, evidence for physicians and parents about which children will have a worsening of their disease after being discharged home from the ED, Dr. Waseem said.

Children younger than 2 years (median 6 months) were enrolled at 30 sites in 15 states during two consecutive bronchiolitis seasons: Dec. 1, 2004, through March 31, 2005, and Dec. 1, 2005, through March 31, 2006. A total of 58% of the Multicenter Airway Research Collaboration cohort's children were male; 38% of patients were white, 31% were black, 26% were Hispanic, and 4% were categorized as other.

Among the 1,243 (85%) patients for whom telephone follow-up was completed at 2 weeks, 722 (58%) were discharged home and met the analysis criteria.

Among the 717 children with relapse data, 121 (17%) had a post-ED relapse event defined as any urgent visit to an ED or clinic for worsening of bronchiolitis during the 2-week follow-up period.

Using a more restrictive definition of worsening of bronchiolitis that included changing the child's medication or hospital admission, 80 children (11%) relapsed, the researchers reported.

Children who had a post-ED relapse event were significantly more likely than those who did not to be younger than 2 months (11% vs. 6%) and male (70% vs. 57%), said Dr. Waseem, an attending physician in emergency medicine at Lincoln Medical and Mental Health Center, Bronx, N.Y., and an associate professor in emergency medicine at Cornell University Medical School, New York.

The study was supported by the Thrasher Research Fund and a data analysis grant from Merck & Co.

Coauthors Dr. Jonathan M. Mansbach and Dr. Carlos A. Camargo disclosed having received investigator-initiated research grants from AstraZeneca PLC, MedImmune Inc., and Merck.

CHICAGO — Age less than 2 months and male gender were significant independent predictors of relapse in children after ED treatment for bronchiolitis, according to a secondary analysis of a prospective, observational multicenter cohort of 1,459 patients.

Almost one in five children relapsed within 2 weeks of discharge from the ED—a number comparable with relapse rates observed in children with asthma, Dr. Muhammad Waseem and colleagues reported at the annual meeting of the American College of Emergency Physicians.

Bronchiolitis is a common condition in children younger than 2 years—yet there is little, if any, evidence for physicians and parents about which children will have a worsening of their disease after being discharged home from the ED, Dr. Waseem said.

Children younger than 2 years (median 6 months) were enrolled at 30 sites in 15 states during two consecutive bronchiolitis seasons: Dec. 1, 2004, through March 31, 2005, and Dec. 1, 2005, through March 31, 2006. A total of 58% of the Multicenter Airway Research Collaboration cohort's children were male; 38% of patients were white, 31% were black, 26% were Hispanic, and 4% were categorized as other.

Among the 1,243 (85%) patients for whom telephone follow-up was completed at 2 weeks, 722 (58%) were discharged home and met the analysis criteria.

Among the 717 children with relapse data, 121 (17%) had a post-ED relapse event defined as any urgent visit to an ED or clinic for worsening of bronchiolitis during the 2-week follow-up period.

Using a more restrictive definition of worsening of bronchiolitis that included changing the child's medication or hospital admission, 80 children (11%) relapsed, the researchers reported.

Children who had a post-ED relapse event were significantly more likely than those who did not to be younger than 2 months (11% vs. 6%) and male (70% vs. 57%), said Dr. Waseem, an attending physician in emergency medicine at Lincoln Medical and Mental Health Center, Bronx, N.Y., and an associate professor in emergency medicine at Cornell University Medical School, New York.

The study was supported by the Thrasher Research Fund and a data analysis grant from Merck & Co.

Coauthors Dr. Jonathan M. Mansbach and Dr. Carlos A. Camargo disclosed having received investigator-initiated research grants from AstraZeneca PLC, MedImmune Inc., and Merck.

CHICAGO – Childhood trauma and family dysfunction were associated with multiple DSM diagnoses on a structured interview in a nationally representative adult sample.

A history of childhood sexual abuse alone significantly increased the likelihood for 18 of 26 DSM-IV lifetime diagnoses in males (mean odds ratio, 3.3) and for 23 of 26 diagnoses in females (mean OR, 3.0), Dr. Frank Putnam reported at the annual meeting of the International Society for Traumatic Stress Studies.

The National Comorbidity Survey-Replication involving 5,692 households inquired about adverse childhood antecedents occurring before age 18 years, including sexual abuse, physical abuse, parental depression, parental substance abuse, being a crime victim, loss of a parent, and exposure to domestic violence. For each participant, a cumulative risk score was calculated by adding the number of adverse childhood antecedents that happened “most of the time” or “all of the time.”

As cumulative risk scores increased from 0 to 4 or more, the mean number of DSM Axis I diagnoses per individual increased in a stepwise fashion, said Dr. Putnam, director of the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center. Individuals with a risk score of 4 or more averaged more than six lifetime DSM diagnoses, compared with less than two diagnoses for those with a risk score of 1. (See box.)

“We set public policy in this country on whether to use hormone replacement therapy in postmenopausal women based on an odds ratio of 1.23, and look at these ratios,” he said. “These are enormous effects.”

The effects were not only large but crossed multiple DSM categories, indicating increased clinical complexity in participants exposed to a high level of childhood trauma or family dysfunction.

More than half of the 252 high-risk respondents had diagnoses that crossed three or more DSM categories.

The pattern of diagnoses also differed for males and females, with posttraumatic stress disorder (PTSD) being diagnosed in 20% or more of females starting at a risk score of 2. In males, PTSD was not a common diagnosis, even with a risk score of 4 or more, Dr. Putnam reported at the meeting, cosponsored by Boston University.

For male survivors of childhood sexual abuse, the most common diagnoses were dysthymia (OR, 5.4); PTSD (OR, 4.3); attention-deficit/hyperactivity disorder (OR, 3.8); agoraphobia (OR, 3.6); and panic disorder (OR, 3.6). In female survivors, the most common diagnoses were bipolar disorder type I (OR, 6.6); drug abuse (OR, 5.2); PTSD (OR, 4.8); alcohol dependence (OR, 4.7); and oppositional-defiant disorder (OR, 4.1).

The survey included face-to-face structured diagnostic interviews conducted in 2001–2003 with a representative sample of the U.S. population, based on census indicators of age, gender, race, education, marital status, and region.

The findings highlight the need for a new developmental trauma disorder diagnosis to help focus care and for early identification of children who have suffered abuse or neglect, Dr. Putnam said in an interview. Dr. Putnam noted that the findings also replicate the results of the seminal Adverse Childhood Events (ACE) study, which identified a strong graded relationship between the breadth of childhood abuse and family dysfunction and multiple health risk factors later in life (Am. J. Prev. Med. 1998;14:245–58).

The current study was sponsored by the Ohio Can Do 4 Kids project. Dr. Putnam disclosed that he has no commercial relationships.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Childhood trauma and family dysfunction were associated with multiple DSM diagnoses on a structured interview in a nationally representative adult sample.

A history of childhood sexual abuse alone significantly increased the likelihood for 18 of 26 DSM-IV lifetime diagnoses in males (mean odds ratio, 3.3) and for 23 of 26 diagnoses in females (mean OR, 3.0), Dr. Frank Putnam reported at the annual meeting of the International Society for Traumatic Stress Studies.

The National Comorbidity Survey-Replication involving 5,692 households inquired about adverse childhood antecedents occurring before age 18 years, including sexual abuse, physical abuse, parental depression, parental substance abuse, being a crime victim, loss of a parent, and exposure to domestic violence. For each participant, a cumulative risk score was calculated by adding the number of adverse childhood antecedents that happened “most of the time” or “all of the time.”

As cumulative risk scores increased from 0 to 4 or more, the mean number of DSM Axis I diagnoses per individual increased in a stepwise fashion, said Dr. Putnam, director of the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center. Individuals with a risk score of 4 or more averaged more than six lifetime DSM diagnoses, compared with less than two diagnoses for those with a risk score of 1. (See box.)

“We set public policy in this country on whether to use hormone replacement therapy in postmenopausal women based on an odds ratio of 1.23, and look at these ratios,” he said. “These are enormous effects.”

The effects were not only large but crossed multiple DSM categories, indicating increased clinical complexity in participants exposed to a high level of childhood trauma or family dysfunction.

More than half of the 252 high-risk respondents had diagnoses that crossed three or more DSM categories.

The pattern of diagnoses also differed for males and females, with posttraumatic stress disorder (PTSD) being diagnosed in 20% or more of females starting at a risk score of 2. In males, PTSD was not a common diagnosis, even with a risk score of 4 or more, Dr. Putnam reported at the meeting, cosponsored by Boston University.

For male survivors of childhood sexual abuse, the most common diagnoses were dysthymia (OR, 5.4); PTSD (OR, 4.3); attention-deficit/hyperactivity disorder (OR, 3.8); agoraphobia (OR, 3.6); and panic disorder (OR, 3.6). In female survivors, the most common diagnoses were bipolar disorder type I (OR, 6.6); drug abuse (OR, 5.2); PTSD (OR, 4.8); alcohol dependence (OR, 4.7); and oppositional-defiant disorder (OR, 4.1).

The survey included face-to-face structured diagnostic interviews conducted in 2001–2003 with a representative sample of the U.S. population, based on census indicators of age, gender, race, education, marital status, and region.

The findings highlight the need for a new developmental trauma disorder diagnosis to help focus care and for early identification of children who have suffered abuse or neglect, Dr. Putnam said in an interview. Dr. Putnam noted that the findings also replicate the results of the seminal Adverse Childhood Events (ACE) study, which identified a strong graded relationship between the breadth of childhood abuse and family dysfunction and multiple health risk factors later in life (Am. J. Prev. Med. 1998;14:245–58).

The current study was sponsored by the Ohio Can Do 4 Kids project. Dr. Putnam disclosed that he has no commercial relationships.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Childhood trauma and family dysfunction were associated with multiple DSM diagnoses on a structured interview in a nationally representative adult sample.

A history of childhood sexual abuse alone significantly increased the likelihood for 18 of 26 DSM-IV lifetime diagnoses in males (mean odds ratio, 3.3) and for 23 of 26 diagnoses in females (mean OR, 3.0), Dr. Frank Putnam reported at the annual meeting of the International Society for Traumatic Stress Studies.

The National Comorbidity Survey-Replication involving 5,692 households inquired about adverse childhood antecedents occurring before age 18 years, including sexual abuse, physical abuse, parental depression, parental substance abuse, being a crime victim, loss of a parent, and exposure to domestic violence. For each participant, a cumulative risk score was calculated by adding the number of adverse childhood antecedents that happened “most of the time” or “all of the time.”

As cumulative risk scores increased from 0 to 4 or more, the mean number of DSM Axis I diagnoses per individual increased in a stepwise fashion, said Dr. Putnam, director of the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center. Individuals with a risk score of 4 or more averaged more than six lifetime DSM diagnoses, compared with less than two diagnoses for those with a risk score of 1. (See box.)

“We set public policy in this country on whether to use hormone replacement therapy in postmenopausal women based on an odds ratio of 1.23, and look at these ratios,” he said. “These are enormous effects.”

The effects were not only large but crossed multiple DSM categories, indicating increased clinical complexity in participants exposed to a high level of childhood trauma or family dysfunction.

More than half of the 252 high-risk respondents had diagnoses that crossed three or more DSM categories.

The pattern of diagnoses also differed for males and females, with posttraumatic stress disorder (PTSD) being diagnosed in 20% or more of females starting at a risk score of 2. In males, PTSD was not a common diagnosis, even with a risk score of 4 or more, Dr. Putnam reported at the meeting, cosponsored by Boston University.

For male survivors of childhood sexual abuse, the most common diagnoses were dysthymia (OR, 5.4); PTSD (OR, 4.3); attention-deficit/hyperactivity disorder (OR, 3.8); agoraphobia (OR, 3.6); and panic disorder (OR, 3.6). In female survivors, the most common diagnoses were bipolar disorder type I (OR, 6.6); drug abuse (OR, 5.2); PTSD (OR, 4.8); alcohol dependence (OR, 4.7); and oppositional-defiant disorder (OR, 4.1).

The survey included face-to-face structured diagnostic interviews conducted in 2001–2003 with a representative sample of the U.S. population, based on census indicators of age, gender, race, education, marital status, and region.

The findings highlight the need for a new developmental trauma disorder diagnosis to help focus care and for early identification of children who have suffered abuse or neglect, Dr. Putnam said in an interview. Dr. Putnam noted that the findings also replicate the results of the seminal Adverse Childhood Events (ACE) study, which identified a strong graded relationship between the breadth of childhood abuse and family dysfunction and multiple health risk factors later in life (Am. J. Prev. Med. 1998;14:245–58).

The current study was sponsored by the Ohio Can Do 4 Kids project. Dr. Putnam disclosed that he has no commercial relationships.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first aid, specialized school-based interventions, and specialized community-based services. “We expect students to come to us when they are in distress, but frankly, it wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre–the fourth deadliest school shooting in United States history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're doing to retraumatize; that did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University. “We had three students after filling out the survey who needed additional support. It was because they couldn't believe we developed this survey that they finally felt that someone got it. It wasn't because they were distressed, it was almost a relief.”

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure–meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest (3.4%) in those with no exposure.

In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%). (See accompanying graphic.)

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and associates concluded.

Dr. Brymer disclosed no relevant conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first aid, specialized school-based interventions, and specialized community-based services. “We expect students to come to us when they are in distress, but frankly, it wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre–the fourth deadliest school shooting in United States history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're doing to retraumatize; that did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University. “We had three students after filling out the survey who needed additional support. It was because they couldn't believe we developed this survey that they finally felt that someone got it. It wasn't because they were distressed, it was almost a relief.”

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure–meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest (3.4%) in those with no exposure.

In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%). (See accompanying graphic.)

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and associates concluded.

Dr. Brymer disclosed no relevant conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Schoolwide mental health screening should be routinely conducted after a school shooting to identify at-risk students and help guide the selection of appropriate treatment strategies.

This conclusion is based on a study that showed roughly one-fourth of the 247 students directly exposed to the shootings at Santana High School in Santee, Calif., suffered from posttraumatic stress disorder or partial PTSD 8–9 months after the March 5, 2001, event in which 2 students died and 13 were injured.

Among all 1,160 students screened, 4.9% met criteria for PTSD and 12.5% met partial criteria for PTSD. Depression was present in 15.4% of all students and 18.7% of those with direct exposure.

This level of distress was present even after the immediate postevent development of a three-tier mental health program of psychological first aid, specialized school-based interventions, and specialized community-based services. “We expect students to come to us when they are in distress, but frankly, it wasn't until we did our screening that we really truly found out which students were at risk,” principal investigator Melissa J. Brymer, Ph.D., Psy.D., said at the annual meeting of the International Society for Traumatic Stress Studies.

This is the first study aimed at evaluating the impact of a school shooting in a high school population. Psychological screening was not conducted after the widely publicized Columbine (Colo.) High School massacre–the fourth deadliest school shooting in United States history and the deadliest for an American high school.

“Many people are concerned that if we screen, we're doing to retraumatize; that did not happen,” Dr. Brymer said at the meeting, which was cosponsored by Boston University. “We had three students after filling out the survey who needed additional support. It was because they couldn't believe we developed this survey that they finally felt that someone got it. It wasn't because they were distressed, it was almost a relief.”

Trauma screening had been planned for September 2001, but was delayed until November and December 2001 because of the Sept. 11 terrorism attacks. In all, 247 students had witnessed a fellow student being shot or receiving medical treatment, 590 students had heard or seen a shot fired from a distance, and 323 students experienced no exposure–meaning they either just witnessed people running or were not on campus during the shootings.

The findings did show a dose-of-exposure pattern for PTSD but not for depression. PTSD rates were highest in students with direct exposure (9.7%) and lowest (3.4%) in those with no exposure.

In contrast, depression peaked in students with direct exposure (18.7%), but was also high in those with no exposure (15.6%). (See accompanying graphic.)

The high rates of depression observed in those without direct exposure to the shootings is typically not seen in disasters caused by natural events. “We need to keep that in mind when we're doing this work,” said Dr. Brymer, director of terrorism and disaster programs, National Center for Child Traumatic Stress, University of California, Los Angeles.

Subjective features of exposure, such as whether the students felt frozen or torn between wanting to help themselves or help others, played a larger role in the development of PTSD than of depression.

The study also identified a significant gender-exposure interaction, with girls in the direct-exposure group scoring significantly higher than their male counterparts for both PTSD and depression.

The findings demonstrate that systematic schoolwide screening after a school shooting is feasible and is an important strategy for identifying at-risk students, Dr. Brymer and associates concluded.

Dr. Brymer disclosed no relevant conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2–3 weeks of treatment, symptoms disappeared completely in 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and 2 patients had no response, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure takes about 15 minutes and requires no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

No adverse events or recurrences have been reported among the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview he added, “Being so simple and cheap, the procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the clinician to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us,” he said. “This could be useful for other pathologies like tennis elbow.”

After the treatment, orthotic plantar support is strongly encouraged, said Dr. Sconfienza, who reported no conflicts of interest.

'There is less pain, less time, and less money' with combination therapy. DR. SCONFIENZA

Ultrasound guidance is used to improve accuracy and avoid injecting steroids directly into the plantar fascia, which could result in rupture. Radiological Society of North America

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2–3 weeks of treatment, symptoms disappeared completely in 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and 2 patients had no response, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure takes about 15 minutes and requires no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

No adverse events or recurrences have been reported among the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview he added, “Being so simple and cheap, the procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the clinician to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us,” he said. “This could be useful for other pathologies like tennis elbow.”

After the treatment, orthotic plantar support is strongly encouraged, said Dr. Sconfienza, who reported no conflicts of interest.

'There is less pain, less time, and less money' with combination therapy. DR. SCONFIENZA

Ultrasound guidance is used to improve accuracy and avoid injecting steroids directly into the plantar fascia, which could result in rupture. Radiological Society of North America

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2–3 weeks of treatment, symptoms disappeared completely in 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and 2 patients had no response, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure takes about 15 minutes and requires no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

No adverse events or recurrences have been reported among the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview he added, “Being so simple and cheap, the procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the clinician to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us,” he said. “This could be useful for other pathologies like tennis elbow.”

After the treatment, orthotic plantar support is strongly encouraged, said Dr. Sconfienza, who reported no conflicts of interest.

'There is less pain, less time, and less money' with combination therapy. DR. SCONFIENZA

Ultrasound guidance is used to improve accuracy and avoid injecting steroids directly into the plantar fascia, which could result in rupture. Radiological Society of North America

CHICAGO — Neuroimaging of patients with atopic dermatitis has shown that different areas of the brain are activated in the itch versus scratch cycles.

The findings provide insight into the the role of peripheral and central neural sensitization of nerve fibers in contributing to atopic dermatitis itch. The findings also support the growing interest in drugs that act as antipruritics to reduce central sensitization, Dr. Gil Yosipovitch said.

Using arterial spin labeling-based functional MRI, Dr. Yosipovitch and colleagues at Wake Forest University, Winston-Salem, N.C., showed that the anterior cingulate cortex and dorsolateral prefrontal cortex are highly activated in patients with atopic dermatitis, but are not activated in healthy subjects when itch is induced. The activity in these cortices is also significantly correlated to itch intensity and disease severity scores in atopic dermatitis, according to unpublished data.

Curious about brain processing during scratching, the investigators, in another study, exposed 13 healthy subjects to a scratching stimulus. They found that repetitive scratching activates areas in the brain not activated in itch, most notably the secondary somatosensory cortex (J. Invest. Dermatol. 2008;128:1806–11). They also found significant activity in the cerebellum, which may be involved in coordinating the itch-scratch cycle.

What was more striking was a robust deactivation of the anterior cingulate cortex, which is involved in the unpleasant sensation of itch and thus may explain why scratching is so pleasurable, said Dr. Yosipovitch. Furthermore, there was a significant correlation between perceived scratching intensity and bilateral deactivation of the cingulate cortex.

"There is a hypersensitization of the nerve fibers in chronic itch; the nerve fibers are acting wacky," he said. "So when you give a painful stimulus instead of it being perceived as pain, it actually aggravates itch. It's very similar to patients with chronic pain, who when you induce an itchy state, it is perceived as pain.

"Now you can understand why one of my treatments of itch is reduction of central sensitization," he said at the American Academy of Dermatology's Academy 2008 meeting

Drugs targeting this mechanism include selective noradrenergic reuptake inhibitors such as mirtazapine, neuroleptics, and kappa opioids.

Butorphanol is an approved kappa agonist and mu-receptor antagonist analgesic that is available in injectable and intranasal spray formulations, he said. Butorphanol nasal spray is very effective in treating patients with chronic, intractable itch that affects their sleep and quality of life.

"I don't want to send the wrong message that this is a first-line drug for itch, but I'm quite sure we all have these patients and sometimes it's worth a try," he said.

Dr. Yosipovitch also uses 15 mg of mirtazapine (Remeron) at bedtime for intractable itch in patients aged 10 years and older, almost half of whom report a significant improvement in sleep and quality of life. The antidepressant is not addictive, but weight gain can occur.

He suggested that the immunosuppressant azathioprine (Imuran), which is used to prevent kidney transplant rejection and to treat severe rheumatoid arthritis, is underutilized in the United States for atopic dermatitis. He acknowledged concerns about the increased risk of lymphoma associated with azathioprine therapy, but said this is unlikely with short-term use of 1 year or less at a dosage of 1 mg/kg.

In a double-blind, randomized trial conducted in the United Kingdom in 63 patients who had moderate to severe atopic eczema despite having received optimum topical therapy, azathioprine dosed by thiopurine methyltransferase (TPMT) was well tolerated; however, two patients developed drug hypersensitivity (Lancet 2006;367:839–46). At week 12, there was a 37% improvement in mean disease activity with azathioprine, compared with a 20% improvement with placebo. Significant improvements in itch, area of involvement, and quality of life were also observed.

Although the psoriasis biologic therapies—efalizumab, alefacept, and rituximab—are being studied for atopic dermatitis, Dr. Yosipovitch said he is not convinced at this point of their efficacy.

Dr. Yosipovitch, known as "Dr. Itch" to his patients, is fond of the old-fashioned remedy of double-layer wet pajamas in which a moist wet-wrap dressing is covered by a layer of dry pajamas. A Korean study in 10 patients with severe atopic dermatitis confirmed that wet-wrap dressings were associated with clinical improvement and recovery of the epidermal barrier (J. Eur. Acad. Dermatol. Venereol. 2007;21:1360–8).

Dr. Yosipovitch disclosed that he has been on the advisory board of, been a consultant for, or received research grant support from, Acologix Inc., Cara Therapeutics, Taisho Pharmaceutical Co., Stiefel Laboratories Inc., UCB Pharma, Connetics Corp., and the National Eczema Association.

A robust deactivation of the anterior cingulate cortex may explain why scratching is so pleasurable. DR. YOSIPOVITCH

CHICAGO — Neuroimaging of patients with atopic dermatitis has shown that different areas of the brain are activated in the itch versus scratch cycles.

The findings provide insight into the the role of peripheral and central neural sensitization of nerve fibers in contributing to atopic dermatitis itch. The findings also support the growing interest in drugs that act as antipruritics to reduce central sensitization, Dr. Gil Yosipovitch said.

Using arterial spin labeling-based functional MRI, Dr. Yosipovitch and colleagues at Wake Forest University, Winston-Salem, N.C., showed that the anterior cingulate cortex and dorsolateral prefrontal cortex are highly activated in patients with atopic dermatitis, but are not activated in healthy subjects when itch is induced. The activity in these cortices is also significantly correlated to itch intensity and disease severity scores in atopic dermatitis, according to unpublished data.

Curious about brain processing during scratching, the investigators, in another study, exposed 13 healthy subjects to a scratching stimulus. They found that repetitive scratching activates areas in the brain not activated in itch, most notably the secondary somatosensory cortex (J. Invest. Dermatol. 2008;128:1806–11). They also found significant activity in the cerebellum, which may be involved in coordinating the itch-scratch cycle.

What was more striking was a robust deactivation of the anterior cingulate cortex, which is involved in the unpleasant sensation of itch and thus may explain why scratching is so pleasurable, said Dr. Yosipovitch. Furthermore, there was a significant correlation between perceived scratching intensity and bilateral deactivation of the cingulate cortex.

"There is a hypersensitization of the nerve fibers in chronic itch; the nerve fibers are acting wacky," he said. "So when you give a painful stimulus instead of it being perceived as pain, it actually aggravates itch. It's very similar to patients with chronic pain, who when you induce an itchy state, it is perceived as pain.

"Now you can understand why one of my treatments of itch is reduction of central sensitization," he said at the American Academy of Dermatology's Academy 2008 meeting

Drugs targeting this mechanism include selective noradrenergic reuptake inhibitors such as mirtazapine, neuroleptics, and kappa opioids.

Butorphanol is an approved kappa agonist and mu-receptor antagonist analgesic that is available in injectable and intranasal spray formulations, he said. Butorphanol nasal spray is very effective in treating patients with chronic, intractable itch that affects their sleep and quality of life.

"I don't want to send the wrong message that this is a first-line drug for itch, but I'm quite sure we all have these patients and sometimes it's worth a try," he said.

Dr. Yosipovitch also uses 15 mg of mirtazapine (Remeron) at bedtime for intractable itch in patients aged 10 years and older, almost half of whom report a significant improvement in sleep and quality of life. The antidepressant is not addictive, but weight gain can occur.

He suggested that the immunosuppressant azathioprine (Imuran), which is used to prevent kidney transplant rejection and to treat severe rheumatoid arthritis, is underutilized in the United States for atopic dermatitis. He acknowledged concerns about the increased risk of lymphoma associated with azathioprine therapy, but said this is unlikely with short-term use of 1 year or less at a dosage of 1 mg/kg.

In a double-blind, randomized trial conducted in the United Kingdom in 63 patients who had moderate to severe atopic eczema despite having received optimum topical therapy, azathioprine dosed by thiopurine methyltransferase (TPMT) was well tolerated; however, two patients developed drug hypersensitivity (Lancet 2006;367:839–46). At week 12, there was a 37% improvement in mean disease activity with azathioprine, compared with a 20% improvement with placebo. Significant improvements in itch, area of involvement, and quality of life were also observed.

Although the psoriasis biologic therapies—efalizumab, alefacept, and rituximab—are being studied for atopic dermatitis, Dr. Yosipovitch said he is not convinced at this point of their efficacy.

Dr. Yosipovitch, known as "Dr. Itch" to his patients, is fond of the old-fashioned remedy of double-layer wet pajamas in which a moist wet-wrap dressing is covered by a layer of dry pajamas. A Korean study in 10 patients with severe atopic dermatitis confirmed that wet-wrap dressings were associated with clinical improvement and recovery of the epidermal barrier (J. Eur. Acad. Dermatol. Venereol. 2007;21:1360–8).

Dr. Yosipovitch disclosed that he has been on the advisory board of, been a consultant for, or received research grant support from, Acologix Inc., Cara Therapeutics, Taisho Pharmaceutical Co., Stiefel Laboratories Inc., UCB Pharma, Connetics Corp., and the National Eczema Association.

A robust deactivation of the anterior cingulate cortex may explain why scratching is so pleasurable. DR. YOSIPOVITCH

CHICAGO — Neuroimaging of patients with atopic dermatitis has shown that different areas of the brain are activated in the itch versus scratch cycles.

The findings provide insight into the the role of peripheral and central neural sensitization of nerve fibers in contributing to atopic dermatitis itch. The findings also support the growing interest in drugs that act as antipruritics to reduce central sensitization, Dr. Gil Yosipovitch said.

Using arterial spin labeling-based functional MRI, Dr. Yosipovitch and colleagues at Wake Forest University, Winston-Salem, N.C., showed that the anterior cingulate cortex and dorsolateral prefrontal cortex are highly activated in patients with atopic dermatitis, but are not activated in healthy subjects when itch is induced. The activity in these cortices is also significantly correlated to itch intensity and disease severity scores in atopic dermatitis, according to unpublished data.

Curious about brain processing during scratching, the investigators, in another study, exposed 13 healthy subjects to a scratching stimulus. They found that repetitive scratching activates areas in the brain not activated in itch, most notably the secondary somatosensory cortex (J. Invest. Dermatol. 2008;128:1806–11). They also found significant activity in the cerebellum, which may be involved in coordinating the itch-scratch cycle.

What was more striking was a robust deactivation of the anterior cingulate cortex, which is involved in the unpleasant sensation of itch and thus may explain why scratching is so pleasurable, said Dr. Yosipovitch. Furthermore, there was a significant correlation between perceived scratching intensity and bilateral deactivation of the cingulate cortex.

"There is a hypersensitization of the nerve fibers in chronic itch; the nerve fibers are acting wacky," he said. "So when you give a painful stimulus instead of it being perceived as pain, it actually aggravates itch. It's very similar to patients with chronic pain, who when you induce an itchy state, it is perceived as pain.

"Now you can understand why one of my treatments of itch is reduction of central sensitization," he said at the American Academy of Dermatology's Academy 2008 meeting

Drugs targeting this mechanism include selective noradrenergic reuptake inhibitors such as mirtazapine, neuroleptics, and kappa opioids.

Butorphanol is an approved kappa agonist and mu-receptor antagonist analgesic that is available in injectable and intranasal spray formulations, he said. Butorphanol nasal spray is very effective in treating patients with chronic, intractable itch that affects their sleep and quality of life.

"I don't want to send the wrong message that this is a first-line drug for itch, but I'm quite sure we all have these patients and sometimes it's worth a try," he said.

Dr. Yosipovitch also uses 15 mg of mirtazapine (Remeron) at bedtime for intractable itch in patients aged 10 years and older, almost half of whom report a significant improvement in sleep and quality of life. The antidepressant is not addictive, but weight gain can occur.

He suggested that the immunosuppressant azathioprine (Imuran), which is used to prevent kidney transplant rejection and to treat severe rheumatoid arthritis, is underutilized in the United States for atopic dermatitis. He acknowledged concerns about the increased risk of lymphoma associated with azathioprine therapy, but said this is unlikely with short-term use of 1 year or less at a dosage of 1 mg/kg.

In a double-blind, randomized trial conducted in the United Kingdom in 63 patients who had moderate to severe atopic eczema despite having received optimum topical therapy, azathioprine dosed by thiopurine methyltransferase (TPMT) was well tolerated; however, two patients developed drug hypersensitivity (Lancet 2006;367:839–46). At week 12, there was a 37% improvement in mean disease activity with azathioprine, compared with a 20% improvement with placebo. Significant improvements in itch, area of involvement, and quality of life were also observed.

Although the psoriasis biologic therapies—efalizumab, alefacept, and rituximab—are being studied for atopic dermatitis, Dr. Yosipovitch said he is not convinced at this point of their efficacy.

Dr. Yosipovitch, known as "Dr. Itch" to his patients, is fond of the old-fashioned remedy of double-layer wet pajamas in which a moist wet-wrap dressing is covered by a layer of dry pajamas. A Korean study in 10 patients with severe atopic dermatitis confirmed that wet-wrap dressings were associated with clinical improvement and recovery of the epidermal barrier (J. Eur. Acad. Dermatol. Venereol. 2007;21:1360–8).

Dr. Yosipovitch disclosed that he has been on the advisory board of, been a consultant for, or received research grant support from, Acologix Inc., Cara Therapeutics, Taisho Pharmaceutical Co., Stiefel Laboratories Inc., UCB Pharma, Connetics Corp., and the National Eczema Association.

A robust deactivation of the anterior cingulate cortex may explain why scratching is so pleasurable. DR. YOSIPOVITCH

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2 to 3 weeks of treatment, symptoms disappeared completely 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and no response occured in 2 patients, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure took about 15 minutes and required no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

At 6 months' follow-up, 41 patients were “very satisfied,” 1 was “satisfied,” and 2 were “unsatisfied.” No adverse events or recurrences have been reported in the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy. The majority of patients were female (89%), and their mean age was 48 years.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview, he added, “The procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the provider to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us. This could be useful for other pathologies like tennis elbow,” he said. Orthotic plantar support is strongly encouraged after treatment.

When asked if steroids or dry needling alone could produce similar results, Dr. Sconfienza acknowledged the lack of a control group in the study, but said previous experience has shown that steroids and dry needling are less effective when used as monotherapy. Future studies are needed to validate the findings, he said.

The investigators reported no conflicts of interest.

Ultrasound guidance ensures steroids are not injected into the plantar fascia. Radiological Society of North America

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2 to 3 weeks of treatment, symptoms disappeared completely 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and no response occured in 2 patients, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure took about 15 minutes and required no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

At 6 months' follow-up, 41 patients were “very satisfied,” 1 was “satisfied,” and 2 were “unsatisfied.” No adverse events or recurrences have been reported in the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy. The majority of patients were female (89%), and their mean age was 48 years.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview, he added, “The procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the provider to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us. This could be useful for other pathologies like tennis elbow,” he said. Orthotic plantar support is strongly encouraged after treatment.

When asked if steroids or dry needling alone could produce similar results, Dr. Sconfienza acknowledged the lack of a control group in the study, but said previous experience has shown that steroids and dry needling are less effective when used as monotherapy. Future studies are needed to validate the findings, he said.

The investigators reported no conflicts of interest.

Ultrasound guidance ensures steroids are not injected into the plantar fascia. Radiological Society of North America

CHICAGO — The combination of ultrasound-guided dry-needling and steroid injection was 95% effective in relieving the heel pain associated with plantar fasciitis in a study of 44 patients.

Within 2 to 3 weeks of treatment, symptoms disappeared completely 39 patients, initial worsening was followed by progressive disappearance of symptoms in 3 patients, and no response occured in 2 patients, Dr. Luca Maria Sconfienza reported at the annual meeting of the Radiological Society of North America.

The one-time outpatient procedure took about 15 minutes and required no time off work or in the hospital, said Dr. Sconfienza, a radiologist with the department of experimental medicine at Genova (Italy) University.

At 6 months' follow-up, 41 patients were “very satisfied,” 1 was “satisfied,” and 2 were “unsatisfied.” No adverse events or recurrences have been reported in the patients, whose plantar fasciitis was previously unresponsive to traditional medical therapy. The majority of patients were female (89%), and their mean age was 48 years.

There is no widely accepted treatment for plantar fasciitis, a common condition that results from thickening and inflammation of the plantar fascia and causes stabbing or burning pain. Many patients are treated with shock waves, but this painful approach typically requires three sessions with 14 days off between sessions, and its long-term effectiveness is not fully documented, Dr. Sconfienza told reporters at a press briefing during the meeting. At $450, shock wave therapy also costs five times the $90 price of the new combination therapy.

“There is less pain, less time, and less money” with combination therapy, Dr. Sconfienza said. In an interview, he added, “The procedure can be performed anywhere and by anyone who underwent a basic training in interventional ultrasound.”

The technique involves injecting a small amount of local anesthesia and, under ultrasound guidance, repeatedly inserting a needle into the plantar fascia and on the periostium. The technique produces a small amount of local bleeding. The needle is then retracted to reach the perifascial soft tissue, where a small amount of steroid (1 mL of triamcinolone acetonide 40 mg/mL) is injected. Ultrasound guidance allows the provider to avoid injecting the drugs directly into the plantar fascia, which could lead to a complete rupture, he said.

The steroid reduces inflammation in the plantar fascia, while the local bleeding takes advantage of growth enzymes in the platelets that promote tissue healing. “We allow nature to work for us. This could be useful for other pathologies like tennis elbow,” he said. Orthotic plantar support is strongly encouraged after treatment.

When asked if steroids or dry needling alone could produce similar results, Dr. Sconfienza acknowledged the lack of a control group in the study, but said previous experience has shown that steroids and dry needling are less effective when used as monotherapy. Future studies are needed to validate the findings, he said.

The investigators reported no conflicts of interest.

Ultrasound guidance ensures steroids are not injected into the plantar fascia. Radiological Society of North America

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and colleagues at Children's Hospital in Philadelphia used magnetoencephalography imaging to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300-500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children. That is about 1/20 of a second, which doesn't sound like much, except that each syllable of speech lasts only about a 1/4 of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years, and roughly 95% were male.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said.

Researchers have made a recording in an 18-month-old, and are recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly by slowing down speech to the affected child.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch an interview with Dr. Roberts, go to: http://www.youtube.com/familypracticenews

Magnetoencephalography can evaluate the timing of brain activity and the propagation of activity from one area of the brain to another. Radiological Society of North America

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and colleagues at Children's Hospital in Philadelphia used magnetoencephalography imaging to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300-500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children. That is about 1/20 of a second, which doesn't sound like much, except that each syllable of speech lasts only about a 1/4 of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years, and roughly 95% were male.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said.

Researchers have made a recording in an 18-month-old, and are recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly by slowing down speech to the affected child.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch an interview with Dr. Roberts, go to: http://www.youtube.com/familypracticenews

Magnetoencephalography can evaluate the timing of brain activity and the propagation of activity from one area of the brain to another. Radiological Society of North America

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and colleagues at Children's Hospital in Philadelphia used magnetoencephalography imaging to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300-500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children. That is about 1/20 of a second, which doesn't sound like much, except that each syllable of speech lasts only about a 1/4 of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years, and roughly 95% were male.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said.

Researchers have made a recording in an 18-month-old, and are recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly by slowing down speech to the affected child.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch an interview with Dr. Roberts, go to: http://www.youtube.com/familypracticenews

Magnetoencephalography can evaluate the timing of brain activity and the propagation of activity from one area of the brain to another. Radiological Society of North America

CHICAGO — Deep brain stimulation of limbic relays within the basal ganglia circuitry reduced tic severity in patients with Tourette syndrome, according to data from a small double-blind, randomized crossover study.

In three patients with severe and medically refractory Tourette syndrome, high-frequency bilateral deep brain stimulation was applied to two structures that form part of the basal ganglia associative-limbic circuits—the centromedian-parafascicular complex (CM-Pf) of the thalamus and the ventromedial part of the globus pallidus interna (GPi). Patients and investigators were blinded at evaluation to the four stimulation conditions—thalamic, pallidal, simultaneous thalamic and pallidal, and sham.

The greatest lessening of tics was achieved with ventromedial GPi stimulation, coinvestigator Dr. Luc Mallet said at the 12th International Congress of Parkinson's Disease and Movement Disorders. The total Yale Global Tic Severity Scale (YGTSS) score was reduced 65%, 96%, and 74% from baseline in patients 1, 2, and 3, respectively. CM-Pf stimulation reduced tic severity by 64%, 30%, and 40%, respectively. Combining thalamic and pallidal stimulation did not improve tic reduction in the study (Arch. Neurol. 2008;65:952–7).

In patient No. 2, the best result was obtained after 1 month with stimulation, but the effects decreased after 2 months, even with increased voltage, said Dr. Mallet of Pitié-Salpêtrière Hospital, Paris.

Very good long-term effects were observed in patient No. 1, who was identified with borderline personality disorder before surgery. The decrease in tic severity was accompanied by a dramatic reduction in self-injurious behaviors and impulsiveness, allowing the patient to start psychotherapy, to improve autonomy and social relationships, and to return to full-time work 2 years after surgery. Although tics are involuntary movements, they are influenced by emotional context, said Dr. Mallet, who disclosed no conflicts of interest.

In patient No. 2, a stable reduction in tic severity was achieved 27 months after surgery using 20 hours of pallidal stimulation followed by 4 hours off. In patient 3, tic severity was reduced by 74% at 20 months without medication under pallidal and thalamic stimulation. No neuropsychological, psychiatric, or other long-term adverse effects were observed.

The findings confirm those of open-label studies and case reports, and support the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia, Dr. Mallet said.

A large French multicenter study is underway to evaluate ventromedial GPi stimulation in patients with Tourette. Ventromedial GPi stimulation may be more efficient than CM-Pf because the GPi is a key structure for the output nucleus of the main basal ganglia pathway, whereas the CM-Pf is part of an indirect, internal loop of the basal ganglia circuitry, the investigators noted.

The current study was also by Dr. Marie-Laure Welter and was sponsored by the French National Institute for Health and Medical Research, the University of Pierre and Marie Curie in Paris, and the Public Assistance Hospital of Paris.

The findings back the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia. DR. MALLET

CHICAGO — Deep brain stimulation of limbic relays within the basal ganglia circuitry reduced tic severity in patients with Tourette syndrome, according to data from a small double-blind, randomized crossover study.

In three patients with severe and medically refractory Tourette syndrome, high-frequency bilateral deep brain stimulation was applied to two structures that form part of the basal ganglia associative-limbic circuits—the centromedian-parafascicular complex (CM-Pf) of the thalamus and the ventromedial part of the globus pallidus interna (GPi). Patients and investigators were blinded at evaluation to the four stimulation conditions—thalamic, pallidal, simultaneous thalamic and pallidal, and sham.

The greatest lessening of tics was achieved with ventromedial GPi stimulation, coinvestigator Dr. Luc Mallet said at the 12th International Congress of Parkinson's Disease and Movement Disorders. The total Yale Global Tic Severity Scale (YGTSS) score was reduced 65%, 96%, and 74% from baseline in patients 1, 2, and 3, respectively. CM-Pf stimulation reduced tic severity by 64%, 30%, and 40%, respectively. Combining thalamic and pallidal stimulation did not improve tic reduction in the study (Arch. Neurol. 2008;65:952–7).

In patient No. 2, the best result was obtained after 1 month with stimulation, but the effects decreased after 2 months, even with increased voltage, said Dr. Mallet of Pitié-Salpêtrière Hospital, Paris.

Very good long-term effects were observed in patient No. 1, who was identified with borderline personality disorder before surgery. The decrease in tic severity was accompanied by a dramatic reduction in self-injurious behaviors and impulsiveness, allowing the patient to start psychotherapy, to improve autonomy and social relationships, and to return to full-time work 2 years after surgery. Although tics are involuntary movements, they are influenced by emotional context, said Dr. Mallet, who disclosed no conflicts of interest.

In patient No. 2, a stable reduction in tic severity was achieved 27 months after surgery using 20 hours of pallidal stimulation followed by 4 hours off. In patient 3, tic severity was reduced by 74% at 20 months without medication under pallidal and thalamic stimulation. No neuropsychological, psychiatric, or other long-term adverse effects were observed.

The findings confirm those of open-label studies and case reports, and support the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia, Dr. Mallet said.

A large French multicenter study is underway to evaluate ventromedial GPi stimulation in patients with Tourette. Ventromedial GPi stimulation may be more efficient than CM-Pf because the GPi is a key structure for the output nucleus of the main basal ganglia pathway, whereas the CM-Pf is part of an indirect, internal loop of the basal ganglia circuitry, the investigators noted.

The current study was also by Dr. Marie-Laure Welter and was sponsored by the French National Institute for Health and Medical Research, the University of Pierre and Marie Curie in Paris, and the Public Assistance Hospital of Paris.

The findings back the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia. DR. MALLET

CHICAGO — Deep brain stimulation of limbic relays within the basal ganglia circuitry reduced tic severity in patients with Tourette syndrome, according to data from a small double-blind, randomized crossover study.

In three patients with severe and medically refractory Tourette syndrome, high-frequency bilateral deep brain stimulation was applied to two structures that form part of the basal ganglia associative-limbic circuits—the centromedian-parafascicular complex (CM-Pf) of the thalamus and the ventromedial part of the globus pallidus interna (GPi). Patients and investigators were blinded at evaluation to the four stimulation conditions—thalamic, pallidal, simultaneous thalamic and pallidal, and sham.

The greatest lessening of tics was achieved with ventromedial GPi stimulation, coinvestigator Dr. Luc Mallet said at the 12th International Congress of Parkinson's Disease and Movement Disorders. The total Yale Global Tic Severity Scale (YGTSS) score was reduced 65%, 96%, and 74% from baseline in patients 1, 2, and 3, respectively. CM-Pf stimulation reduced tic severity by 64%, 30%, and 40%, respectively. Combining thalamic and pallidal stimulation did not improve tic reduction in the study (Arch. Neurol. 2008;65:952–7).

In patient No. 2, the best result was obtained after 1 month with stimulation, but the effects decreased after 2 months, even with increased voltage, said Dr. Mallet of Pitié-Salpêtrière Hospital, Paris.

Very good long-term effects were observed in patient No. 1, who was identified with borderline personality disorder before surgery. The decrease in tic severity was accompanied by a dramatic reduction in self-injurious behaviors and impulsiveness, allowing the patient to start psychotherapy, to improve autonomy and social relationships, and to return to full-time work 2 years after surgery. Although tics are involuntary movements, they are influenced by emotional context, said Dr. Mallet, who disclosed no conflicts of interest.

In patient No. 2, a stable reduction in tic severity was achieved 27 months after surgery using 20 hours of pallidal stimulation followed by 4 hours off. In patient 3, tic severity was reduced by 74% at 20 months without medication under pallidal and thalamic stimulation. No neuropsychological, psychiatric, or other long-term adverse effects were observed.

The findings confirm those of open-label studies and case reports, and support the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia, Dr. Mallet said.

A large French multicenter study is underway to evaluate ventromedial GPi stimulation in patients with Tourette. Ventromedial GPi stimulation may be more efficient than CM-Pf because the GPi is a key structure for the output nucleus of the main basal ganglia pathway, whereas the CM-Pf is part of an indirect, internal loop of the basal ganglia circuitry, the investigators noted.

The current study was also by Dr. Marie-Laure Welter and was sponsored by the French National Institute for Health and Medical Research, the University of Pierre and Marie Curie in Paris, and the Public Assistance Hospital of Paris.

The findings back the theory that Tourette results from dysfunction of the associative-limbic territories of the basal ganglia. DR. MALLET

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and his colleagues at Children's Hospital in Philadelphia (CHOP) used a type of imaging called magnetoencephalography to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years and roughly 95% were male.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300–500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children.

Forty to 50 milliseconds is about one-twentieth of a second, which doesn't sound like much unless one considers that each syllable of speech lasts only about a quarter of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said in an interview that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't have this particular deficit, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said. Such split-second measurements are beyond the scope of spatial or locationist modalities like MRI or PET.

The investigators have successfully made a recording in an 18-month-old, and are currently recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly in the form of slowing down speech to the affected child.

Unfortunately, there are only 100 MEG machines in the world and two in the U.S. And in a time of global economic slowdown, MEG is an expensive technology, with a price tag of $2 million for the machine alone.

There have been previous reports of MEG in autism, but the research was quite speculative and related autism to its overlap with epilepsy phenotypes, he said.

Future studies may also investigate differences in brain activity between the alpha, beta, and gamma power bands—a phenomenon that has recently been observed in patients with Parkinson's. In the current study, the only significant difference between bands was abnormal patterns of predominantly lower-intensity gamma oscillation in the superior temporal gyrus of children with autism, Dr. Roberts said.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch a video interview of Dr. Roberts, go to: http://www.youtube.com/watch?v=yoBQ3G3WhiA

Children with autism had pronounced response delays in the midfrequency ranges that are key to human speech. RADIOLOGICAL SOCIETY OF NORTH AMERICA

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and his colleagues at Children's Hospital in Philadelphia (CHOP) used a type of imaging called magnetoencephalography to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years and roughly 95% were male.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300–500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children.

Forty to 50 milliseconds is about one-twentieth of a second, which doesn't sound like much unless one considers that each syllable of speech lasts only about a quarter of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said in an interview that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't have this particular deficit, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said. Such split-second measurements are beyond the scope of spatial or locationist modalities like MRI or PET.

The investigators have successfully made a recording in an 18-month-old, and are currently recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly in the form of slowing down speech to the affected child.

Unfortunately, there are only 100 MEG machines in the world and two in the U.S. And in a time of global economic slowdown, MEG is an expensive technology, with a price tag of $2 million for the machine alone.

There have been previous reports of MEG in autism, but the research was quite speculative and related autism to its overlap with epilepsy phenotypes, he said.

Future studies may also investigate differences in brain activity between the alpha, beta, and gamma power bands—a phenomenon that has recently been observed in patients with Parkinson's. In the current study, the only significant difference between bands was abnormal patterns of predominantly lower-intensity gamma oscillation in the superior temporal gyrus of children with autism, Dr. Roberts said.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch a video interview of Dr. Roberts, go to: http://www.youtube.com/watch?v=yoBQ3G3WhiA

Children with autism had pronounced response delays in the midfrequency ranges that are key to human speech. RADIOLOGICAL SOCIETY OF NORTH AMERICA

CHICAGO — Researchers have identified delays in auditory processing in the brains of children with autism spectrum disorders.

Although the response to various sounds is delayed by only a fraction of a second, this delay may underpin the subsequent language and communication impairment seen in children with autism, principal investigator Timothy Roberts, Ph.D., reported at the annual meeting of the Radiological Society of North America.

Dr. Roberts and his colleagues at Children's Hospital in Philadelphia (CHOP) used a type of imaging called magnetoencephalography to measure the electromagnetic field produced during neuronal activation in 30 children with autism spectrum disorders, with or without concomitant language impairment, and 34 age-matched typically developing controls

Getting children to sit still for any kind of testing can be challenging, with recordings possible in 51 (80%) of the cohort. Their mean age was 10 years and roughly 95% were male.

Recordings were made using a 275-channel whole-head unit while the children were watching a silent movie of their choice without performing any tasks.

When introduced to single tones ranging in frequency from 100 Hz to 1,000 Hz, there was a strong evoked response in typically developing children and a consistent and significant delay of about 20 milliseconds in the response of children with autism.

The delay was particularly pronounced at the midrange tones of 300–500 Hz—the frequency range where the bulk of human speech is located, Dr. Roberts said.

“This is a very critical range to be manifesting such a delay in processing sounds,” he said. “It's like the signal to have a response simply doesn't get to that part of the brain on time, like when the freeway is clogged up with cars and you can't get to where you're going on time. That delay can have downstream consequences.”

When the children were introduced to mismatched tones, there was a significant 35- to 50-millisecond delay in the brains of autistic children to register that one tone was different from another. The delay was most pronounced in the autistic children with language impairment, averaging 40 milliseconds slower than typically developing children.

Forty to 50 milliseconds is about one-twentieth of a second, which doesn't sound like much unless one considers that each syllable of speech lasts only about a quarter of a second, said Dr. Roberts, vice chair of research in the department of radiology at Children's Hospital in Philadelphia.

“To have a 50-millisecond delay in registering that a syllable has changed could be catastrophic,” he said. For example, with the word “elephant,” he said, “you're still dealing with the 'el' when everyone else has moved on to the 'phant.' You can never catch up, and this could be catastrophic.”

As for how the findings might be used in clinical practice, Dr. Roberts said in an interview that they are hoping to use brain activity patterns to establish a “suite of biomarkers” for autism that could be used to improve classification of the disorder and guide treatment.

“It may be that we start addressing the heterogeneity of the autistic population by subtyping,” he said. “Based on that subtyping, one might triage these patients into different behavioral interventions. It's speculative, but it suggests that if you have an auditory processing deficit that part of your therapy ought to be working on improving auditory processing, whereas if you don't have this particular deficit, then maybe your intervention should target something else.”

In a step toward that goal, the investigators used receiver operating characteristic curves to determine if latency responses to various sounds could distinguish study participants with autism from those without the disorder.

What they found was a significant correlation between autism and the response to a single beep tone in the 500-Hz range, resulting in a sensitivity of 82% and specificity of 70%. The correlation was also significant when mismatched tones were used as stimuli, producing a sensitivity of 88% and specificity of 74%, Dr. Roberts reported.

Magnetoencephalography (MEG) has typically been used for epilepsy evaluations, but is emerging as a neurologic/radiologic tool. It lends itself to disorders of connectivity such as autism or Parkinson's disease because of its ability to evaluate the timing of brain activity and the propagation of activity from one area of the brain to another, Dr. Roberts said.

“MEG gives us a reasonable idea of the spatial location of the activity, but gives us a wonderful view of the timing of it,” he said. Such split-second measurements are beyond the scope of spatial or locationist modalities like MRI or PET.

The investigators have successfully made a recording in an 18-month-old, and are currently recruiting 100 families to study the use of MEG in neonates and young children. The hope is for early intervention during the crucial stage of language development, possibly in the form of slowing down speech to the affected child.

Unfortunately, there are only 100 MEG machines in the world and two in the U.S. And in a time of global economic slowdown, MEG is an expensive technology, with a price tag of $2 million for the machine alone.

There have been previous reports of MEG in autism, but the research was quite speculative and related autism to its overlap with epilepsy phenotypes, he said.

Future studies may also investigate differences in brain activity between the alpha, beta, and gamma power bands—a phenomenon that has recently been observed in patients with Parkinson's. In the current study, the only significant difference between bands was abnormal patterns of predominantly lower-intensity gamma oscillation in the superior temporal gyrus of children with autism, Dr. Roberts said.

The study was sponsored by the National Institutes of Health and the Nancy Lurie Marks Family Foundation. The investigators reported no conflicts of interest.

To watch a video interview of Dr. Roberts, go to: http://www.youtube.com/watch?v=yoBQ3G3WhiA

Children with autism had pronounced response delays in the midfrequency ranges that are key to human speech. RADIOLOGICAL SOCIETY OF NORTH AMERICA