Patrice Wendling

TUCSON, ARIZ. – Nutritional rehabilitation may require involuntary hospitalization in patients with eating disorders. “These behaviors can be easily defined as self-harming behaviors, and these patients can and should be committed if they fall below a certain weight,” Dr. Chelsea Chesen reported at a psychopharmacology conference sponsored by the University of Arizona.

The most important rules for a psychiatrist are to put safety first, take a multidisciplinary approach rather than going it alone, and create an individualized treatment plan.

Weight goals should be realistic, but there also needs to be an understanding that, should the patient fail to meet the goal, there will be certain consequences, including hospitalization. A weight gain of 0.5–1.5 pounds/week is appropriate for outpatients, and 2–3 pounds/week for inpatients, said Dr. Chesen, of the psychiatry department at the university.

Clinicians should consult with a nutritionist, if possible, to develop regular, structured diets for their patients. They also might want to adopt a behavioral contract with the patient or the patient's parent for eating meals and choosing foods. Anxiolytics given 30–60 minutes before meals can help patients with anxiety about eating.

It is particularly important to encourage patients with anorexia to eat small, frequent meals, typically about six a day. “Part of the reason for that is that they will be extremely uncomfortable physically if they take in a large amount of food because their gut won't know what to do with it, and it takes time to literally process the food,” she said.

Some patients referred to Dr. Chesen have been on total parenteral nutrition, but this approach doesn't teach the gut to work properly for the long term and can cause liver abnormalities, she said.

If nasogastric feeding is necessary, she recommends using the smallest tube possible, such as a pediatric tube, and feeding continuously over 24 hours at the slowest possible rate. A bolus or gastrostomy tube should not be used to administer feedings.

Too-rapid refeeding is a major problem in patients with anorexia, because their bodies can become overwhelmed with the sudden intake of nutrients, leading to severe fluid retention, electrolyte disturbances, arrhythmias, seizures, coma, and death. “You want to be really gentle and really slow,” Dr. Chesen said. “Keep in mind that they didn't get this way overnight, so you're not going to get them healthy overnight.”

Physical examinations and laboratory evaluations should be performed every 2 weeks, especially in patients who are severely malnourished at the start of treatment. Clinicians should be aware that during refeeding, changes in body shape and clothing fit can trigger severe anxiety or depression.

All patients with eating disorders should take a multivitamin plus vitamin D and calcium. Because of the risk of death secondary to cardiac arrhythmias in patients with anorexia, clinicians should consider oral vitamin K supplementation, which has been shown to normalize the QT interval. “I'm not saying you should put every anorexic on potassium, but they should have an EKG, and their potassium levels should be followed by their primary care physician,” she said.

TUCSON, ARIZ. – Nutritional rehabilitation may require involuntary hospitalization in patients with eating disorders. “These behaviors can be easily defined as self-harming behaviors, and these patients can and should be committed if they fall below a certain weight,” Dr. Chelsea Chesen reported at a psychopharmacology conference sponsored by the University of Arizona.

The most important rules for a psychiatrist are to put safety first, take a multidisciplinary approach rather than going it alone, and create an individualized treatment plan.

Weight goals should be realistic, but there also needs to be an understanding that, should the patient fail to meet the goal, there will be certain consequences, including hospitalization. A weight gain of 0.5–1.5 pounds/week is appropriate for outpatients, and 2–3 pounds/week for inpatients, said Dr. Chesen, of the psychiatry department at the university.

Clinicians should consult with a nutritionist, if possible, to develop regular, structured diets for their patients. They also might want to adopt a behavioral contract with the patient or the patient's parent for eating meals and choosing foods. Anxiolytics given 30–60 minutes before meals can help patients with anxiety about eating.

It is particularly important to encourage patients with anorexia to eat small, frequent meals, typically about six a day. “Part of the reason for that is that they will be extremely uncomfortable physically if they take in a large amount of food because their gut won't know what to do with it, and it takes time to literally process the food,” she said.

Some patients referred to Dr. Chesen have been on total parenteral nutrition, but this approach doesn't teach the gut to work properly for the long term and can cause liver abnormalities, she said.

If nasogastric feeding is necessary, she recommends using the smallest tube possible, such as a pediatric tube, and feeding continuously over 24 hours at the slowest possible rate. A bolus or gastrostomy tube should not be used to administer feedings.

Too-rapid refeeding is a major problem in patients with anorexia, because their bodies can become overwhelmed with the sudden intake of nutrients, leading to severe fluid retention, electrolyte disturbances, arrhythmias, seizures, coma, and death. “You want to be really gentle and really slow,” Dr. Chesen said. “Keep in mind that they didn't get this way overnight, so you're not going to get them healthy overnight.”

Physical examinations and laboratory evaluations should be performed every 2 weeks, especially in patients who are severely malnourished at the start of treatment. Clinicians should be aware that during refeeding, changes in body shape and clothing fit can trigger severe anxiety or depression.

All patients with eating disorders should take a multivitamin plus vitamin D and calcium. Because of the risk of death secondary to cardiac arrhythmias in patients with anorexia, clinicians should consider oral vitamin K supplementation, which has been shown to normalize the QT interval. “I'm not saying you should put every anorexic on potassium, but they should have an EKG, and their potassium levels should be followed by their primary care physician,” she said.

TUCSON, ARIZ. – Nutritional rehabilitation may require involuntary hospitalization in patients with eating disorders. “These behaviors can be easily defined as self-harming behaviors, and these patients can and should be committed if they fall below a certain weight,” Dr. Chelsea Chesen reported at a psychopharmacology conference sponsored by the University of Arizona.

The most important rules for a psychiatrist are to put safety first, take a multidisciplinary approach rather than going it alone, and create an individualized treatment plan.

Weight goals should be realistic, but there also needs to be an understanding that, should the patient fail to meet the goal, there will be certain consequences, including hospitalization. A weight gain of 0.5–1.5 pounds/week is appropriate for outpatients, and 2–3 pounds/week for inpatients, said Dr. Chesen, of the psychiatry department at the university.

Clinicians should consult with a nutritionist, if possible, to develop regular, structured diets for their patients. They also might want to adopt a behavioral contract with the patient or the patient's parent for eating meals and choosing foods. Anxiolytics given 30–60 minutes before meals can help patients with anxiety about eating.

It is particularly important to encourage patients with anorexia to eat small, frequent meals, typically about six a day. “Part of the reason for that is that they will be extremely uncomfortable physically if they take in a large amount of food because their gut won't know what to do with it, and it takes time to literally process the food,” she said.

Some patients referred to Dr. Chesen have been on total parenteral nutrition, but this approach doesn't teach the gut to work properly for the long term and can cause liver abnormalities, she said.

If nasogastric feeding is necessary, she recommends using the smallest tube possible, such as a pediatric tube, and feeding continuously over 24 hours at the slowest possible rate. A bolus or gastrostomy tube should not be used to administer feedings.

Too-rapid refeeding is a major problem in patients with anorexia, because their bodies can become overwhelmed with the sudden intake of nutrients, leading to severe fluid retention, electrolyte disturbances, arrhythmias, seizures, coma, and death. “You want to be really gentle and really slow,” Dr. Chesen said. “Keep in mind that they didn't get this way overnight, so you're not going to get them healthy overnight.”

Physical examinations and laboratory evaluations should be performed every 2 weeks, especially in patients who are severely malnourished at the start of treatment. Clinicians should be aware that during refeeding, changes in body shape and clothing fit can trigger severe anxiety or depression.

All patients with eating disorders should take a multivitamin plus vitamin D and calcium. Because of the risk of death secondary to cardiac arrhythmias in patients with anorexia, clinicians should consider oral vitamin K supplementation, which has been shown to normalize the QT interval. “I'm not saying you should put every anorexic on potassium, but they should have an EKG, and their potassium levels should be followed by their primary care physician,” she said.

ROSEMONT, IL. – Experimental technologies for evaluating patients with suspected mild cognitive impairment hold great promise, but until their clinical relevance is well understood, they should not be used in routine practice, Dr. Paul B. Rosenberg said at a conference sponsored by the American Association for Geriatric Psychiatry.

Clinically, magnetic resonance imaging (MRI)is already useful for ruling out unusual causes of cognitive impairment such as a brain mass, occult subdural hematoma, and stroke, said Dr. Rosenberg, a neuropsychiatrist with Johns Hopkins University, Baltimore.

In the research arena, however, MRI is being taken to the next level. By visualizing hippocampal volume loss in patients, for example, the imaging technology is helping to define subtypes of mild cognitive impairment (MCI).

Likewise, genotyping is being used to identify carriers of the apolipoprotein ϵ4 (apo ϵ4) allele, which has been shown to be associated with an elevated risk of converting to Alzheimer's disease. But for many reasons, these experimental applications of available technologies should remain in the research setting for now, Dr. Rosenberg cautioned.

Genotyping for apo ϵ4 is particularly controversial. “Personally, I'd like to do it for my own curiosity, but ethically I don't. … I'm worried about patients getting blackballed. The mere fact that a patient got tested [for apo ϵ4] may bar them from getting long-term care insurance,” he said.

Clinicians may be tempted to perform genotyping because of a study in which the treatment effect of donepezil (Aricept) was more significant and lasting in patients who were apo ϵ4 positive (N. Engl. J. Med. 2005;352:2379–88). But the same investigation also showed that donepezil was no more effective than vitamin E or placebo in slowing progression to Alzheimer's at 36 months.

The results underscore the need for more effective interventions before routine genotyping would be practical, Dr. Rosenberg said.

Unlike Alzheimer's patients, who are often unaware of their cognitive decline, people with MCI will complain of memory problems when they present. “These are the most anxious patients I've ever worked with. … They are absolutely terrified they have [gotten] that disease [Alzheimer's], and it's no less scary than thinking you've got cancer,” he said.

The diagnostic work-up for MCI should include interviews, family and medical histories, functional assessments, and psychiatric, cognitive, and neurologic exams.

During interviews, be alert to complaints about forgetting names, problems doing bills, repeating stories, and forgetting appointments. Getting lost in unfamiliar environments is frequently the first sign of MCI, he said.

MCI patients rarely present with complaints that they no longer remember how to do things such as drive a car, which is a well-ingrained skill that doesn't require much short-term recall.

Patients and family members should be interviewed separately to avoid prompting and to tease out difficult issues such as violence.

If a cognitive deficit isn't indicated in the patient history, it's unlikely it will be found on further examination, he noted.

Functional assessments should address topics such as activities of daily living, social life, and functioning on a job. But with retirement, cognitive impairment may be less apparent as patients face fewer cognitive challenges in their daily lives.

A past history or current symptoms of depression, anxiety, or irritability on a psychiatric exam are particularly noteworthy because they are risk factors for conversion to dementia.

Results from a prospective study indicated that a staggering 85% of MCI patients who were depressed went on to develop dementia at 3 years, compared with only 32% of nondepressed MCI patients (Arch. Neurol. 2004;61:1290–3).

ROSEMONT, IL. – Experimental technologies for evaluating patients with suspected mild cognitive impairment hold great promise, but until their clinical relevance is well understood, they should not be used in routine practice, Dr. Paul B. Rosenberg said at a conference sponsored by the American Association for Geriatric Psychiatry.

Clinically, magnetic resonance imaging (MRI)is already useful for ruling out unusual causes of cognitive impairment such as a brain mass, occult subdural hematoma, and stroke, said Dr. Rosenberg, a neuropsychiatrist with Johns Hopkins University, Baltimore.

In the research arena, however, MRI is being taken to the next level. By visualizing hippocampal volume loss in patients, for example, the imaging technology is helping to define subtypes of mild cognitive impairment (MCI).

Likewise, genotyping is being used to identify carriers of the apolipoprotein ϵ4 (apo ϵ4) allele, which has been shown to be associated with an elevated risk of converting to Alzheimer's disease. But for many reasons, these experimental applications of available technologies should remain in the research setting for now, Dr. Rosenberg cautioned.

Genotyping for apo ϵ4 is particularly controversial. “Personally, I'd like to do it for my own curiosity, but ethically I don't. … I'm worried about patients getting blackballed. The mere fact that a patient got tested [for apo ϵ4] may bar them from getting long-term care insurance,” he said.

Clinicians may be tempted to perform genotyping because of a study in which the treatment effect of donepezil (Aricept) was more significant and lasting in patients who were apo ϵ4 positive (N. Engl. J. Med. 2005;352:2379–88). But the same investigation also showed that donepezil was no more effective than vitamin E or placebo in slowing progression to Alzheimer's at 36 months.

The results underscore the need for more effective interventions before routine genotyping would be practical, Dr. Rosenberg said.

Unlike Alzheimer's patients, who are often unaware of their cognitive decline, people with MCI will complain of memory problems when they present. “These are the most anxious patients I've ever worked with. … They are absolutely terrified they have [gotten] that disease [Alzheimer's], and it's no less scary than thinking you've got cancer,” he said.

The diagnostic work-up for MCI should include interviews, family and medical histories, functional assessments, and psychiatric, cognitive, and neurologic exams.

During interviews, be alert to complaints about forgetting names, problems doing bills, repeating stories, and forgetting appointments. Getting lost in unfamiliar environments is frequently the first sign of MCI, he said.

MCI patients rarely present with complaints that they no longer remember how to do things such as drive a car, which is a well-ingrained skill that doesn't require much short-term recall.

Patients and family members should be interviewed separately to avoid prompting and to tease out difficult issues such as violence.

If a cognitive deficit isn't indicated in the patient history, it's unlikely it will be found on further examination, he noted.

Functional assessments should address topics such as activities of daily living, social life, and functioning on a job. But with retirement, cognitive impairment may be less apparent as patients face fewer cognitive challenges in their daily lives.

A past history or current symptoms of depression, anxiety, or irritability on a psychiatric exam are particularly noteworthy because they are risk factors for conversion to dementia.

Results from a prospective study indicated that a staggering 85% of MCI patients who were depressed went on to develop dementia at 3 years, compared with only 32% of nondepressed MCI patients (Arch. Neurol. 2004;61:1290–3).

ROSEMONT, IL. – Experimental technologies for evaluating patients with suspected mild cognitive impairment hold great promise, but until their clinical relevance is well understood, they should not be used in routine practice, Dr. Paul B. Rosenberg said at a conference sponsored by the American Association for Geriatric Psychiatry.

Clinically, magnetic resonance imaging (MRI)is already useful for ruling out unusual causes of cognitive impairment such as a brain mass, occult subdural hematoma, and stroke, said Dr. Rosenberg, a neuropsychiatrist with Johns Hopkins University, Baltimore.

In the research arena, however, MRI is being taken to the next level. By visualizing hippocampal volume loss in patients, for example, the imaging technology is helping to define subtypes of mild cognitive impairment (MCI).

Likewise, genotyping is being used to identify carriers of the apolipoprotein ϵ4 (apo ϵ4) allele, which has been shown to be associated with an elevated risk of converting to Alzheimer's disease. But for many reasons, these experimental applications of available technologies should remain in the research setting for now, Dr. Rosenberg cautioned.

Genotyping for apo ϵ4 is particularly controversial. “Personally, I'd like to do it for my own curiosity, but ethically I don't. … I'm worried about patients getting blackballed. The mere fact that a patient got tested [for apo ϵ4] may bar them from getting long-term care insurance,” he said.

Clinicians may be tempted to perform genotyping because of a study in which the treatment effect of donepezil (Aricept) was more significant and lasting in patients who were apo ϵ4 positive (N. Engl. J. Med. 2005;352:2379–88). But the same investigation also showed that donepezil was no more effective than vitamin E or placebo in slowing progression to Alzheimer's at 36 months.

The results underscore the need for more effective interventions before routine genotyping would be practical, Dr. Rosenberg said.

Unlike Alzheimer's patients, who are often unaware of their cognitive decline, people with MCI will complain of memory problems when they present. “These are the most anxious patients I've ever worked with. … They are absolutely terrified they have [gotten] that disease [Alzheimer's], and it's no less scary than thinking you've got cancer,” he said.

The diagnostic work-up for MCI should include interviews, family and medical histories, functional assessments, and psychiatric, cognitive, and neurologic exams.

During interviews, be alert to complaints about forgetting names, problems doing bills, repeating stories, and forgetting appointments. Getting lost in unfamiliar environments is frequently the first sign of MCI, he said.

MCI patients rarely present with complaints that they no longer remember how to do things such as drive a car, which is a well-ingrained skill that doesn't require much short-term recall.

Patients and family members should be interviewed separately to avoid prompting and to tease out difficult issues such as violence.

If a cognitive deficit isn't indicated in the patient history, it's unlikely it will be found on further examination, he noted.

Functional assessments should address topics such as activities of daily living, social life, and functioning on a job. But with retirement, cognitive impairment may be less apparent as patients face fewer cognitive challenges in their daily lives.

A past history or current symptoms of depression, anxiety, or irritability on a psychiatric exam are particularly noteworthy because they are risk factors for conversion to dementia.

Results from a prospective study indicated that a staggering 85% of MCI patients who were depressed went on to develop dementia at 3 years, compared with only 32% of nondepressed MCI patients (Arch. Neurol. 2004;61:1290–3).

TUCSON, ARIZ. – Two new studies support the use of methylphenidate in treating hyperactivity in children with autism.

The results contradict much of the historical data showing that psychostimulants are not helpful in this population but confirm what many psychiatrists are using in clinical practice for autism and autism spectrum disorders.

In the first study, 11 preschool children with autism received gradually titrated doses in an open-label fashion with methylphenidate hydrochloride 1.25–10 mg twice daily after a 1-week lead-in phase. Then the children were randomized to their optimal dose for 2 weeks and placebo for 2 weeks, in either order. The children ranged in age from 41 months to 72 months; the mean age was 5 years.

Methylphenidate was successful in reducing the hyperactivity/impulsivity subscale of the Conners' Parent Ratings Scale and the Children's Global Assessment Scale. Further analysis of the double-blind data is needed, but the results of the open-label phase are encouraging, author Dr. Jaswinder K. Ghuman said at a psychopharmacology conference sponsored by the University of Arizona.

“These children have many problems, so parents and teachers feel that any small improvement is worth it, even though the response is not as robust as in children without developmental disabilities,” Dr. Ghuman said in an interview. “With a small improvement, they are more manageable in the classroom, and able to benefit from other psychosocial and educational interventions.”

There were seven mild to moderate adverse events, including reduced appetite (in 2 patients), sleepiness or feeling tired (2), difficulty sleeping (2), and mood lability (1).

None of the events led to discontinuation of the medication but did lead to dose increases being limited, which may have made the response less robust, said Dr. Ghuman of the psychiatry department at the University of Arizona, Tucson, and director of its infant and preschool program.

Anecdotal reports have linked psychostimulants with a high frequency of adverse events. Children with autism may be more likely to respond to stimulants with irritability, mood lability, and worsening of stereotypic and repetitive behaviors, so care needs to be exercised in starting the children at a low dose, with relatively slower titration and frequent regular monitoring, she said.

In a recent separate, double-blind, placebo-controlled crossover study, adverse events led to the discontinuation of methylphenidate in 13 (18%) of 72 children with autism and hyperactivity (Arch. Gen. Psychiatry 2005;62:1266–74). Doses in the study were based on patient weight and ranged from 7.5 mg/day to 50 mg/day in divided doses.

Methylphenidate was superior to placebo in reducing scores on the teacher-rated hyperactivity subscale of the Aberrant Behavior Checklist, with effect sizes ranging from 0.20 to 0.54 depending on the dose and rater.

Overall, 35 (49%) of the 72 children were classified as methylphenidate responders. The placebo response rate was 20%.

Popular belief is that children with a lower IQ and younger children do not respond as well to methylphenidate. But there was no difference in response because of IQ level below or above 50 points, a diagnosis of autism or Asperger's disorder, or age, which ranged from 5 years to 14 years.

Further study is needed to replicate these findings and to see whether they could be generalized to the everyday clinical setting, Dr. Ghuman said.

TUCSON, ARIZ. – Two new studies support the use of methylphenidate in treating hyperactivity in children with autism.

The results contradict much of the historical data showing that psychostimulants are not helpful in this population but confirm what many psychiatrists are using in clinical practice for autism and autism spectrum disorders.

In the first study, 11 preschool children with autism received gradually titrated doses in an open-label fashion with methylphenidate hydrochloride 1.25–10 mg twice daily after a 1-week lead-in phase. Then the children were randomized to their optimal dose for 2 weeks and placebo for 2 weeks, in either order. The children ranged in age from 41 months to 72 months; the mean age was 5 years.

Methylphenidate was successful in reducing the hyperactivity/impulsivity subscale of the Conners' Parent Ratings Scale and the Children's Global Assessment Scale. Further analysis of the double-blind data is needed, but the results of the open-label phase are encouraging, author Dr. Jaswinder K. Ghuman said at a psychopharmacology conference sponsored by the University of Arizona.

“These children have many problems, so parents and teachers feel that any small improvement is worth it, even though the response is not as robust as in children without developmental disabilities,” Dr. Ghuman said in an interview. “With a small improvement, they are more manageable in the classroom, and able to benefit from other psychosocial and educational interventions.”

There were seven mild to moderate adverse events, including reduced appetite (in 2 patients), sleepiness or feeling tired (2), difficulty sleeping (2), and mood lability (1).

None of the events led to discontinuation of the medication but did lead to dose increases being limited, which may have made the response less robust, said Dr. Ghuman of the psychiatry department at the University of Arizona, Tucson, and director of its infant and preschool program.

Anecdotal reports have linked psychostimulants with a high frequency of adverse events. Children with autism may be more likely to respond to stimulants with irritability, mood lability, and worsening of stereotypic and repetitive behaviors, so care needs to be exercised in starting the children at a low dose, with relatively slower titration and frequent regular monitoring, she said.

In a recent separate, double-blind, placebo-controlled crossover study, adverse events led to the discontinuation of methylphenidate in 13 (18%) of 72 children with autism and hyperactivity (Arch. Gen. Psychiatry 2005;62:1266–74). Doses in the study were based on patient weight and ranged from 7.5 mg/day to 50 mg/day in divided doses.

Methylphenidate was superior to placebo in reducing scores on the teacher-rated hyperactivity subscale of the Aberrant Behavior Checklist, with effect sizes ranging from 0.20 to 0.54 depending on the dose and rater.

Overall, 35 (49%) of the 72 children were classified as methylphenidate responders. The placebo response rate was 20%.

Popular belief is that children with a lower IQ and younger children do not respond as well to methylphenidate. But there was no difference in response because of IQ level below or above 50 points, a diagnosis of autism or Asperger's disorder, or age, which ranged from 5 years to 14 years.

Further study is needed to replicate these findings and to see whether they could be generalized to the everyday clinical setting, Dr. Ghuman said.

TUCSON, ARIZ. – Two new studies support the use of methylphenidate in treating hyperactivity in children with autism.

The results contradict much of the historical data showing that psychostimulants are not helpful in this population but confirm what many psychiatrists are using in clinical practice for autism and autism spectrum disorders.

In the first study, 11 preschool children with autism received gradually titrated doses in an open-label fashion with methylphenidate hydrochloride 1.25–10 mg twice daily after a 1-week lead-in phase. Then the children were randomized to their optimal dose for 2 weeks and placebo for 2 weeks, in either order. The children ranged in age from 41 months to 72 months; the mean age was 5 years.

Methylphenidate was successful in reducing the hyperactivity/impulsivity subscale of the Conners' Parent Ratings Scale and the Children's Global Assessment Scale. Further analysis of the double-blind data is needed, but the results of the open-label phase are encouraging, author Dr. Jaswinder K. Ghuman said at a psychopharmacology conference sponsored by the University of Arizona.

“These children have many problems, so parents and teachers feel that any small improvement is worth it, even though the response is not as robust as in children without developmental disabilities,” Dr. Ghuman said in an interview. “With a small improvement, they are more manageable in the classroom, and able to benefit from other psychosocial and educational interventions.”

There were seven mild to moderate adverse events, including reduced appetite (in 2 patients), sleepiness or feeling tired (2), difficulty sleeping (2), and mood lability (1).

None of the events led to discontinuation of the medication but did lead to dose increases being limited, which may have made the response less robust, said Dr. Ghuman of the psychiatry department at the University of Arizona, Tucson, and director of its infant and preschool program.

Anecdotal reports have linked psychostimulants with a high frequency of adverse events. Children with autism may be more likely to respond to stimulants with irritability, mood lability, and worsening of stereotypic and repetitive behaviors, so care needs to be exercised in starting the children at a low dose, with relatively slower titration and frequent regular monitoring, she said.

In a recent separate, double-blind, placebo-controlled crossover study, adverse events led to the discontinuation of methylphenidate in 13 (18%) of 72 children with autism and hyperactivity (Arch. Gen. Psychiatry 2005;62:1266–74). Doses in the study were based on patient weight and ranged from 7.5 mg/day to 50 mg/day in divided doses.

Methylphenidate was superior to placebo in reducing scores on the teacher-rated hyperactivity subscale of the Aberrant Behavior Checklist, with effect sizes ranging from 0.20 to 0.54 depending on the dose and rater.

Overall, 35 (49%) of the 72 children were classified as methylphenidate responders. The placebo response rate was 20%.

Popular belief is that children with a lower IQ and younger children do not respond as well to methylphenidate. But there was no difference in response because of IQ level below or above 50 points, a diagnosis of autism or Asperger's disorder, or age, which ranged from 5 years to 14 years.

Further study is needed to replicate these findings and to see whether they could be generalized to the everyday clinical setting, Dr. Ghuman said.

CHICAGO — Solid thyroid nodules smaller than 1 cm in diameter tend to carry a greater risk of papillary carcinoma than do larger nodules, Dr. Nagesh Ragavendra reported at the annual meeting of the Radiological Society of North America.

The results of this study using fine-needle nonaspiration need to be confirmed in larger investigations as the study was too small to establish statistical significance. But the trend was marked: The risk was 16% for thyroid nodules 1 cm or less in diameter compared with 8% for nodules 1.1 cm or more, Dr. Ragavendra said.

Surprisingly, the study also found that capsular invasion is relatively common in solid thyroid nodules, said Dr. Ragavendra, professor of radiology and chief of the ultrasound section at the University of California at Los Angeles.

Five of the larger-sized nodules had capsular invasion; two had nodal metastases, he reported.

The biopsies were performed under ultrasound guidance on 598 focal thyroid nodules in 466 consecutive patients using the fine-needle nonaspiration technique with on-site cytologic examination.

With this technique, cells are extracted with a 25-gauge needle that is repeatedly and rapidly advanced into and withdrawn from the nodule. The needle is not connected to external suction, as is the case with traditional fine-needle aspiration, Dr. Ragavendra explained.

Neither technique has been established as superior in the cytopathologic investigation of thyroid nodules. But fine-needle nonaspiration provides specimens that offer larger numbers of cells and have better preserved cytomorphology, he said.

The sample tends to be less blood tinged with nonaspiration than with aspiration fine-needle biopsy. Further, nonaspiration allows continuous monitoring of the position of the needle tip, thus ensuring proper sampling of the area of interest, Dr. Ragavendra added.

Of the 511 nodules that were 1.1 cm in diameter or larger, histology revealed that 448 (88%) were benign, 39 (8%) were papillary carcinoma, and 24 (5%) were other tumors.

Of the 87 nodules 1 cm or less, 67 (77%) were benign, 14 (16%) were papillary carcinoma, and 6 (7%) were other tumors, he said.

The study does not resolve the long-standing debate as to which thyroid nodules should be biopsied. But those with some cystic components tend to be benign, Dr. Ragavendra said.

At UCLA, all solid nodules, whether hypoechoic or isoechoic, are candidates for fine-needle biopsy, he said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Solid thyroid nodules smaller than 1 cm in diameter tend to carry a greater risk of papillary carcinoma than do larger nodules, Dr. Nagesh Ragavendra reported at the annual meeting of the Radiological Society of North America.

The results of this study using fine-needle nonaspiration need to be confirmed in larger investigations as the study was too small to establish statistical significance. But the trend was marked: The risk was 16% for thyroid nodules 1 cm or less in diameter compared with 8% for nodules 1.1 cm or more, Dr. Ragavendra said.

Surprisingly, the study also found that capsular invasion is relatively common in solid thyroid nodules, said Dr. Ragavendra, professor of radiology and chief of the ultrasound section at the University of California at Los Angeles.

Five of the larger-sized nodules had capsular invasion; two had nodal metastases, he reported.

The biopsies were performed under ultrasound guidance on 598 focal thyroid nodules in 466 consecutive patients using the fine-needle nonaspiration technique with on-site cytologic examination.

With this technique, cells are extracted with a 25-gauge needle that is repeatedly and rapidly advanced into and withdrawn from the nodule. The needle is not connected to external suction, as is the case with traditional fine-needle aspiration, Dr. Ragavendra explained.

Neither technique has been established as superior in the cytopathologic investigation of thyroid nodules. But fine-needle nonaspiration provides specimens that offer larger numbers of cells and have better preserved cytomorphology, he said.

The sample tends to be less blood tinged with nonaspiration than with aspiration fine-needle biopsy. Further, nonaspiration allows continuous monitoring of the position of the needle tip, thus ensuring proper sampling of the area of interest, Dr. Ragavendra added.

Of the 511 nodules that were 1.1 cm in diameter or larger, histology revealed that 448 (88%) were benign, 39 (8%) were papillary carcinoma, and 24 (5%) were other tumors.

Of the 87 nodules 1 cm or less, 67 (77%) were benign, 14 (16%) were papillary carcinoma, and 6 (7%) were other tumors, he said.

The study does not resolve the long-standing debate as to which thyroid nodules should be biopsied. But those with some cystic components tend to be benign, Dr. Ragavendra said.

At UCLA, all solid nodules, whether hypoechoic or isoechoic, are candidates for fine-needle biopsy, he said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Solid thyroid nodules smaller than 1 cm in diameter tend to carry a greater risk of papillary carcinoma than do larger nodules, Dr. Nagesh Ragavendra reported at the annual meeting of the Radiological Society of North America.

The results of this study using fine-needle nonaspiration need to be confirmed in larger investigations as the study was too small to establish statistical significance. But the trend was marked: The risk was 16% for thyroid nodules 1 cm or less in diameter compared with 8% for nodules 1.1 cm or more, Dr. Ragavendra said.

Surprisingly, the study also found that capsular invasion is relatively common in solid thyroid nodules, said Dr. Ragavendra, professor of radiology and chief of the ultrasound section at the University of California at Los Angeles.

Five of the larger-sized nodules had capsular invasion; two had nodal metastases, he reported.

The biopsies were performed under ultrasound guidance on 598 focal thyroid nodules in 466 consecutive patients using the fine-needle nonaspiration technique with on-site cytologic examination.

With this technique, cells are extracted with a 25-gauge needle that is repeatedly and rapidly advanced into and withdrawn from the nodule. The needle is not connected to external suction, as is the case with traditional fine-needle aspiration, Dr. Ragavendra explained.

Neither technique has been established as superior in the cytopathologic investigation of thyroid nodules. But fine-needle nonaspiration provides specimens that offer larger numbers of cells and have better preserved cytomorphology, he said.

The sample tends to be less blood tinged with nonaspiration than with aspiration fine-needle biopsy. Further, nonaspiration allows continuous monitoring of the position of the needle tip, thus ensuring proper sampling of the area of interest, Dr. Ragavendra added.

Of the 511 nodules that were 1.1 cm in diameter or larger, histology revealed that 448 (88%) were benign, 39 (8%) were papillary carcinoma, and 24 (5%) were other tumors.

Of the 87 nodules 1 cm or less, 67 (77%) were benign, 14 (16%) were papillary carcinoma, and 6 (7%) were other tumors, he said.

The study does not resolve the long-standing debate as to which thyroid nodules should be biopsied. But those with some cystic components tend to be benign, Dr. Ragavendra said.

At UCLA, all solid nodules, whether hypoechoic or isoechoic, are candidates for fine-needle biopsy, he said.

ELSEVIER GLOBAL MEDICAL NEWS

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, family history, smoking, duration of perimenopause, endocrine measures, vitamin or mineral supplements, exercise, or medical illnesses (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if all women are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, director of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors—such as aging parents, children leaving home, marital issues, and the individual woman's feelings about growing older and leaving the reproductive years—also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Selective serotonin reuptake inhibitors are an attractive potential option for mood and somatic symptoms of perimenopause, particularly given the controversy surrounding the use of hormone therapy.

Dr. Freeman and her colleagues recently conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, family history, smoking, duration of perimenopause, endocrine measures, vitamin or mineral supplements, exercise, or medical illnesses (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if all women are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, director of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors—such as aging parents, children leaving home, marital issues, and the individual woman's feelings about growing older and leaving the reproductive years—also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Selective serotonin reuptake inhibitors are an attractive potential option for mood and somatic symptoms of perimenopause, particularly given the controversy surrounding the use of hormone therapy.

Dr. Freeman and her colleagues recently conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, family history, smoking, duration of perimenopause, endocrine measures, vitamin or mineral supplements, exercise, or medical illnesses (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if all women are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, director of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors—such as aging parents, children leaving home, marital issues, and the individual woman's feelings about growing older and leaving the reproductive years—also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Selective serotonin reuptake inhibitors are an attractive potential option for mood and somatic symptoms of perimenopause, particularly given the controversy surrounding the use of hormone therapy.

Dr. Freeman and her colleagues recently conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control study.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease. The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test. Electrodiagnostic studies were used to confirm the diagnosis.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control study.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease. The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test. Electrodiagnostic studies were used to confirm the diagnosis.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control study.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease. The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test. Electrodiagnostic studies were used to confirm the diagnosis.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

CHICAGO — Laparoscopic excision of endometriotic lesions of the uterosacral ligament improves not only deep dyspareunia but also the quality of patients' sex life, Dr. Simone Ferrero said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Pain during intercourse affects 60%–79% of women with endometriosis who undergo surgery.

Among women with deep dyspareunia, those with deep infiltrating endometriosis of the uterosacral ligament have the most severe impairment of sexual function, said Dr. Ferrero of San Martino Hospital and the University of Genoa, Italy.

He presented a prospective study in which 64 women with deep dyspareunia were surveyed before surgical excision of endometriotic lesions and 1 year after surgery using a questionnaire based on the sexual satisfaction subscale of the Derogatis Sexual Functioning Inventory, additional questions regarding the characteristics of dyspareunia, the Global Sexual Satisfaction Index, and a 100-mm visual analog scale to measure the intensity of dyspareunia.

All of the women received 6 months of postoperative treatment with the gonadotropin-releasing hormone analogue, triptorelin.

The main indications for surgery were pain symptoms (29), ovarian cysts (20), and infertility (15).

At 1-year follow-up, 29 women had no deep dyspareunia, 25 had decreased intensity, and 10 experienced no change.

Patients had had significantly more intercourse per week in the previous 3 months (1.3 vs. 2.3), more satisfying orgasms (2.3 vs. 4.4), were more relaxed and fulfilled after sex (3.2 vs. 4.5), and were less frequently interrupted by pain during intercourse (3.7 vs. 2).

Global Sexual Satisfaction Index scores also significantly improved (P less than or equal to.001). The surgery didn't significantly change whether the women were “usually satisfied” with their particular partner (5 vs. 5.2).

Women in the study had been with their partners for an average of 11 years; 42 were married, 10 cohabiting, 6 engaged, and 6 single. The average age of the women was 34 years.

CHICAGO — Laparoscopic excision of endometriotic lesions of the uterosacral ligament improves not only deep dyspareunia but also the quality of patients' sex life, Dr. Simone Ferrero said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Pain during intercourse affects 60%–79% of women with endometriosis who undergo surgery.

Among women with deep dyspareunia, those with deep infiltrating endometriosis of the uterosacral ligament have the most severe impairment of sexual function, said Dr. Ferrero of San Martino Hospital and the University of Genoa, Italy.

He presented a prospective study in which 64 women with deep dyspareunia were surveyed before surgical excision of endometriotic lesions and 1 year after surgery using a questionnaire based on the sexual satisfaction subscale of the Derogatis Sexual Functioning Inventory, additional questions regarding the characteristics of dyspareunia, the Global Sexual Satisfaction Index, and a 100-mm visual analog scale to measure the intensity of dyspareunia.

All of the women received 6 months of postoperative treatment with the gonadotropin-releasing hormone analogue, triptorelin.

The main indications for surgery were pain symptoms (29), ovarian cysts (20), and infertility (15).

At 1-year follow-up, 29 women had no deep dyspareunia, 25 had decreased intensity, and 10 experienced no change.

Patients had had significantly more intercourse per week in the previous 3 months (1.3 vs. 2.3), more satisfying orgasms (2.3 vs. 4.4), were more relaxed and fulfilled after sex (3.2 vs. 4.5), and were less frequently interrupted by pain during intercourse (3.7 vs. 2).

Global Sexual Satisfaction Index scores also significantly improved (P less than or equal to.001). The surgery didn't significantly change whether the women were “usually satisfied” with their particular partner (5 vs. 5.2).

Women in the study had been with their partners for an average of 11 years; 42 were married, 10 cohabiting, 6 engaged, and 6 single. The average age of the women was 34 years.

CHICAGO — Laparoscopic excision of endometriotic lesions of the uterosacral ligament improves not only deep dyspareunia but also the quality of patients' sex life, Dr. Simone Ferrero said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Pain during intercourse affects 60%–79% of women with endometriosis who undergo surgery.

Among women with deep dyspareunia, those with deep infiltrating endometriosis of the uterosacral ligament have the most severe impairment of sexual function, said Dr. Ferrero of San Martino Hospital and the University of Genoa, Italy.

He presented a prospective study in which 64 women with deep dyspareunia were surveyed before surgical excision of endometriotic lesions and 1 year after surgery using a questionnaire based on the sexual satisfaction subscale of the Derogatis Sexual Functioning Inventory, additional questions regarding the characteristics of dyspareunia, the Global Sexual Satisfaction Index, and a 100-mm visual analog scale to measure the intensity of dyspareunia.

All of the women received 6 months of postoperative treatment with the gonadotropin-releasing hormone analogue, triptorelin.

The main indications for surgery were pain symptoms (29), ovarian cysts (20), and infertility (15).

At 1-year follow-up, 29 women had no deep dyspareunia, 25 had decreased intensity, and 10 experienced no change.

Patients had had significantly more intercourse per week in the previous 3 months (1.3 vs. 2.3), more satisfying orgasms (2.3 vs. 4.4), were more relaxed and fulfilled after sex (3.2 vs. 4.5), and were less frequently interrupted by pain during intercourse (3.7 vs. 2).

Global Sexual Satisfaction Index scores also significantly improved (P less than or equal to.001). The surgery didn't significantly change whether the women were “usually satisfied” with their particular partner (5 vs. 5.2).

Women in the study had been with their partners for an average of 11 years; 42 were married, 10 cohabiting, 6 engaged, and 6 single. The average age of the women was 34 years.

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, and family history (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if for all women they are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Dr. Freeman and her colleagues conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, and family history (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if for all women they are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Dr. Freeman and her colleagues conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.

The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).

But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, and family history (Am. J. Psychiatry 2004;161:2238–44).

“We don't know if for all women they are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, of the Women's Mental Health Program at the University of Arizona, Tucson.

In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.

Dr. Freeman and her colleagues conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.

An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.

Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).

QUEBEC CITY — Canadian researchers think they've found a way to improve the difficult task of diabetes management by using a Web-based, real-time tracking system linked to patients' electronic medical records.

Diabetes care is often suboptimal because of the need to monitor multiple variables with evolving targets and the difficulty in promoting patient self-care, Lisa Dolovich, Pharm.D., reported at the annual meeting of the North American Primary Care Research Group.

The Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness study's COMPETE II diabetes tracker is available to both patients and physicians and electronically displays 13 standardized variables, including blood glucose, hemoglobin A_1c levels, blood pressure, blood lipid levels, urinary albumin-creatinine ratios, and the most recent foot and eye examinations.

The color-coded chart compares the data with the patients' specific target goals and signals with clock icons which variables are on target and which need further attention.

There are also short advice messages and links to current best evidence on diabetes targets and strategies to obtain them.

Physicians' versions are linked to patients' electronic medical records. Patients are also linked to an automated telephone-reminder system for medication refills, lab tests, and visits, and to transmit information back to their clinicians.

Dr. Dolovich presented data from the COMPETE II study, in which 511 patients with type 2 diabetes under the care of 48 community-based primary care physicians were randomized to the tracker or usual care.

The study's primary outcome was the change from baseline to 6 months in the quality of monitoring 8 of the 13 variables, compared with targets for each patient. A composite score was assigned each patient, with a maximum of 11 points.

At a mean follow-up of 8.5 months, the mean composite score significantly improved in the intervention group, compared with the control group (change of 2.35 vs. 0.80).

Actual blood pressure and hemoglobin A_1c values also significantly improved in the intervention group, compared with the control group. Compared with the control group, diastolic blood pressure was reduced by 2.62 mm Hg, systolic blood pressure by 4.09 mm Hg, and hemoglobin A_1c by 0.2% in the intervention group.

Despite being repeatedly nudged by telephone reminders, 192 (76%) of 253 intervention patients said they were as satisfied or more satisfied with their care as a result of the intervention, and 63% opted to continue receiving automated reminders.

Both patients and physicians rated the benefits of computerization as outweighing the potential health information-privacy risks, reported Dr. Dolovich and Dr. Anne Holbrook, lead author, both of the Centre for Evaluation of Medicines and McMaster University, Hamilton, Ont.

Patients enjoyed having access to their own information and receiving customized advice, whereas the tracker streamlined care for physicians by ensuring that patients' lab tests were done before their office visits.

However, a significant number of older adults in the study never use a computer and preferred a printed version of the tracker. In addition, there were some initial glitches with the technology, and at times, data had to be updated by staff after interviews with patients, Dr. Dolovich said.

Audience members suggested that the tracker required too much effort for such small clinical improvements.

The improvements in clinical outcomes were statistically significant, and there was a trend toward overall improved diabetes outcomes in a short follow-up period, she said.

A larger randomized controlled trial involving 1,100 participants is underway, and a vascular tracker is currently being evaluated.

QUEBEC CITY — Canadian researchers think they've found a way to improve the difficult task of diabetes management by using a Web-based, real-time tracking system linked to patients' electronic medical records.

Diabetes care is often suboptimal because of the need to monitor multiple variables with evolving targets and the difficulty in promoting patient self-care, Lisa Dolovich, Pharm.D., reported at the annual meeting of the North American Primary Care Research Group.

The Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness study's COMPETE II diabetes tracker is available to both patients and physicians and electronically displays 13 standardized variables, including blood glucose, hemoglobin A_1c levels, blood pressure, blood lipid levels, urinary albumin-creatinine ratios, and the most recent foot and eye examinations.

The color-coded chart compares the data with the patients' specific target goals and signals with clock icons which variables are on target and which need further attention.

There are also short advice messages and links to current best evidence on diabetes targets and strategies to obtain them.

Physicians' versions are linked to patients' electronic medical records. Patients are also linked to an automated telephone-reminder system for medication refills, lab tests, and visits, and to transmit information back to their clinicians.

Dr. Dolovich presented data from the COMPETE II study, in which 511 patients with type 2 diabetes under the care of 48 community-based primary care physicians were randomized to the tracker or usual care.

The study's primary outcome was the change from baseline to 6 months in the quality of monitoring 8 of the 13 variables, compared with targets for each patient. A composite score was assigned each patient, with a maximum of 11 points.

At a mean follow-up of 8.5 months, the mean composite score significantly improved in the intervention group, compared with the control group (change of 2.35 vs. 0.80).

Actual blood pressure and hemoglobin A_1c values also significantly improved in the intervention group, compared with the control group. Compared with the control group, diastolic blood pressure was reduced by 2.62 mm Hg, systolic blood pressure by 4.09 mm Hg, and hemoglobin A_1c by 0.2% in the intervention group.

Despite being repeatedly nudged by telephone reminders, 192 (76%) of 253 intervention patients said they were as satisfied or more satisfied with their care as a result of the intervention, and 63% opted to continue receiving automated reminders.

Both patients and physicians rated the benefits of computerization as outweighing the potential health information-privacy risks, reported Dr. Dolovich and Dr. Anne Holbrook, lead author, both of the Centre for Evaluation of Medicines and McMaster University, Hamilton, Ont.

Patients enjoyed having access to their own information and receiving customized advice, whereas the tracker streamlined care for physicians by ensuring that patients' lab tests were done before their office visits.

However, a significant number of older adults in the study never use a computer and preferred a printed version of the tracker. In addition, there were some initial glitches with the technology, and at times, data had to be updated by staff after interviews with patients, Dr. Dolovich said.

Audience members suggested that the tracker required too much effort for such small clinical improvements.

The improvements in clinical outcomes were statistically significant, and there was a trend toward overall improved diabetes outcomes in a short follow-up period, she said.

A larger randomized controlled trial involving 1,100 participants is underway, and a vascular tracker is currently being evaluated.

QUEBEC CITY — Canadian researchers think they've found a way to improve the difficult task of diabetes management by using a Web-based, real-time tracking system linked to patients' electronic medical records.

Diabetes care is often suboptimal because of the need to monitor multiple variables with evolving targets and the difficulty in promoting patient self-care, Lisa Dolovich, Pharm.D., reported at the annual meeting of the North American Primary Care Research Group.

The Computerization of Medical Practices for the Enhancement of Therapeutic Effectiveness study's COMPETE II diabetes tracker is available to both patients and physicians and electronically displays 13 standardized variables, including blood glucose, hemoglobin A_1c levels, blood pressure, blood lipid levels, urinary albumin-creatinine ratios, and the most recent foot and eye examinations.

The color-coded chart compares the data with the patients' specific target goals and signals with clock icons which variables are on target and which need further attention.

There are also short advice messages and links to current best evidence on diabetes targets and strategies to obtain them.

Physicians' versions are linked to patients' electronic medical records. Patients are also linked to an automated telephone-reminder system for medication refills, lab tests, and visits, and to transmit information back to their clinicians.

Dr. Dolovich presented data from the COMPETE II study, in which 511 patients with type 2 diabetes under the care of 48 community-based primary care physicians were randomized to the tracker or usual care.

The study's primary outcome was the change from baseline to 6 months in the quality of monitoring 8 of the 13 variables, compared with targets for each patient. A composite score was assigned each patient, with a maximum of 11 points.

At a mean follow-up of 8.5 months, the mean composite score significantly improved in the intervention group, compared with the control group (change of 2.35 vs. 0.80).

Actual blood pressure and hemoglobin A_1c values also significantly improved in the intervention group, compared with the control group. Compared with the control group, diastolic blood pressure was reduced by 2.62 mm Hg, systolic blood pressure by 4.09 mm Hg, and hemoglobin A_1c by 0.2% in the intervention group.

Despite being repeatedly nudged by telephone reminders, 192 (76%) of 253 intervention patients said they were as satisfied or more satisfied with their care as a result of the intervention, and 63% opted to continue receiving automated reminders.

Both patients and physicians rated the benefits of computerization as outweighing the potential health information-privacy risks, reported Dr. Dolovich and Dr. Anne Holbrook, lead author, both of the Centre for Evaluation of Medicines and McMaster University, Hamilton, Ont.

Patients enjoyed having access to their own information and receiving customized advice, whereas the tracker streamlined care for physicians by ensuring that patients' lab tests were done before their office visits.

However, a significant number of older adults in the study never use a computer and preferred a printed version of the tracker. In addition, there were some initial glitches with the technology, and at times, data had to be updated by staff after interviews with patients, Dr. Dolovich said.

Audience members suggested that the tracker required too much effort for such small clinical improvements.

The improvements in clinical outcomes were statistically significant, and there was a trend toward overall improved diabetes outcomes in a short follow-up period, she said.

A larger randomized controlled trial involving 1,100 participants is underway, and a vascular tracker is currently being evaluated.

CHICAGO — The accuracy of PET-CT for detecting recurrent ovarian cancer is high, Dr. Sunit Sebastian said at the annual meeting of the Radiological Society of North America.

The diagnosis of early recurrence is challenging due to the small size of peritoneal metastases, he said.

In a retrospective study, integrated PET-CT imaging proved to be more accurate than CT alone or PET alone for detecting ovarian cancer recurrence either above or below the diaphragm, reported Dr. Sebastian, who was at Massachusetts General Hospital in Boston at the time of the study.

The analysis included 54 consecutive CT, PET, and PET-CT examinations that were performed at the hospital on 53 women for tumor recurrence after primary debulking surgery for histologically proven ovarian cancer.

One patient underwent PET-CT examination twice.

PET-CT scans of the neck, chest, abdomen, and pelvis were performed with negative oral contrast on a fusion PET-CT scanner.

Delayed PET images were obtained 1 hour later. Finally, a diagnostic CT scan was performed with intravenous contrast and negative oral contrast.

A nuclear medicine radiologist and an abdominal radiologist independently reviewed the diagnostic CT and PET scans, and then reviewed the PET-CT fusion study together.

A gynecologic oncologist provided the standard for recurrent disease based on a clinical record review that took place 3 months after the scans.

The gynecologic oncologist and the readers were blinded to each others' reports, Dr. Sebastian said.

Sensitivity, specificity, and accuracy were each calculated with 95% confidence intervals.

For the entire body, the sensitivity for CT was 35/38 (92%), 31/38 (82%) for PET, and 37/38 (97%) for PET-CT.

Specificity for CT was 9/15 (60%), 10/15 (67%) for PET, and 12/15 (80%) for PET-CT.

Accuracy for CT was 44/53 (83%), 41/53 (77%) for PET, and 49/53 (92%) for PET-CT, said Dr. Sebastian, now a senior research associate in the division of radiology, Emory University School of Medicine, Atlanta.

For the neck and chest, the accuracy was 47/53 (89%) for CT, 48/53 (91%) for PET, and 51/53 (96%) for PET-CT. For the abdomen and pelvis, the accuracy was 42/53 (79%), 42/53 (79%) for PET, and 48/53 (91%) for PET-CT.

Dr. Sebastian suggested that women with ovarian cancer should be routinely evaluated with PET-CT 4–6 months after surgery.

Ideally, a CT scan of the chest should be included as part of the work-up because about 5% of patients with recurrent ovarian cancer will have metastatic disease in the chest without identifiable recurrence in the abdomen and pelvis. For economic reasons, a chest x-ray at least would be helpful, he said.

CHICAGO — The accuracy of PET-CT for detecting recurrent ovarian cancer is high, Dr. Sunit Sebastian said at the annual meeting of the Radiological Society of North America.

The diagnosis of early recurrence is challenging due to the small size of peritoneal metastases, he said.

In a retrospective study, integrated PET-CT imaging proved to be more accurate than CT alone or PET alone for detecting ovarian cancer recurrence either above or below the diaphragm, reported Dr. Sebastian, who was at Massachusetts General Hospital in Boston at the time of the study.

The analysis included 54 consecutive CT, PET, and PET-CT examinations that were performed at the hospital on 53 women for tumor recurrence after primary debulking surgery for histologically proven ovarian cancer.

One patient underwent PET-CT examination twice.

PET-CT scans of the neck, chest, abdomen, and pelvis were performed with negative oral contrast on a fusion PET-CT scanner.

Delayed PET images were obtained 1 hour later. Finally, a diagnostic CT scan was performed with intravenous contrast and negative oral contrast.

A nuclear medicine radiologist and an abdominal radiologist independently reviewed the diagnostic CT and PET scans, and then reviewed the PET-CT fusion study together.

A gynecologic oncologist provided the standard for recurrent disease based on a clinical record review that took place 3 months after the scans.

The gynecologic oncologist and the readers were blinded to each others' reports, Dr. Sebastian said.

Sensitivity, specificity, and accuracy were each calculated with 95% confidence intervals.

For the entire body, the sensitivity for CT was 35/38 (92%), 31/38 (82%) for PET, and 37/38 (97%) for PET-CT.

Specificity for CT was 9/15 (60%), 10/15 (67%) for PET, and 12/15 (80%) for PET-CT.

Accuracy for CT was 44/53 (83%), 41/53 (77%) for PET, and 49/53 (92%) for PET-CT, said Dr. Sebastian, now a senior research associate in the division of radiology, Emory University School of Medicine, Atlanta.

For the neck and chest, the accuracy was 47/53 (89%) for CT, 48/53 (91%) for PET, and 51/53 (96%) for PET-CT. For the abdomen and pelvis, the accuracy was 42/53 (79%), 42/53 (79%) for PET, and 48/53 (91%) for PET-CT.

Dr. Sebastian suggested that women with ovarian cancer should be routinely evaluated with PET-CT 4–6 months after surgery.

Ideally, a CT scan of the chest should be included as part of the work-up because about 5% of patients with recurrent ovarian cancer will have metastatic disease in the chest without identifiable recurrence in the abdomen and pelvis. For economic reasons, a chest x-ray at least would be helpful, he said.

CHICAGO — The accuracy of PET-CT for detecting recurrent ovarian cancer is high, Dr. Sunit Sebastian said at the annual meeting of the Radiological Society of North America.

The diagnosis of early recurrence is challenging due to the small size of peritoneal metastases, he said.

In a retrospective study, integrated PET-CT imaging proved to be more accurate than CT alone or PET alone for detecting ovarian cancer recurrence either above or below the diaphragm, reported Dr. Sebastian, who was at Massachusetts General Hospital in Boston at the time of the study.

The analysis included 54 consecutive CT, PET, and PET-CT examinations that were performed at the hospital on 53 women for tumor recurrence after primary debulking surgery for histologically proven ovarian cancer.

One patient underwent PET-CT examination twice.

PET-CT scans of the neck, chest, abdomen, and pelvis were performed with negative oral contrast on a fusion PET-CT scanner.

Delayed PET images were obtained 1 hour later. Finally, a diagnostic CT scan was performed with intravenous contrast and negative oral contrast.

A nuclear medicine radiologist and an abdominal radiologist independently reviewed the diagnostic CT and PET scans, and then reviewed the PET-CT fusion study together.

A gynecologic oncologist provided the standard for recurrent disease based on a clinical record review that took place 3 months after the scans.

The gynecologic oncologist and the readers were blinded to each others' reports, Dr. Sebastian said.

Sensitivity, specificity, and accuracy were each calculated with 95% confidence intervals.

For the entire body, the sensitivity for CT was 35/38 (92%), 31/38 (82%) for PET, and 37/38 (97%) for PET-CT.

Specificity for CT was 9/15 (60%), 10/15 (67%) for PET, and 12/15 (80%) for PET-CT.

Accuracy for CT was 44/53 (83%), 41/53 (77%) for PET, and 49/53 (92%) for PET-CT, said Dr. Sebastian, now a senior research associate in the division of radiology, Emory University School of Medicine, Atlanta.

For the neck and chest, the accuracy was 47/53 (89%) for CT, 48/53 (91%) for PET, and 51/53 (96%) for PET-CT. For the abdomen and pelvis, the accuracy was 42/53 (79%), 42/53 (79%) for PET, and 48/53 (91%) for PET-CT.

Dr. Sebastian suggested that women with ovarian cancer should be routinely evaluated with PET-CT 4–6 months after surgery.

Ideally, a CT scan of the chest should be included as part of the work-up because about 5% of patients with recurrent ovarian cancer will have metastatic disease in the chest without identifiable recurrence in the abdomen and pelvis. For economic reasons, a chest x-ray at least would be helpful, he said.