Patrice Wendling

CHICAGO — High folate intake may lower the risk of hypertension, particularly in young women, according to data presented at a conference of the Council for High Blood Pressure Research.

Young women who consumed at least 800 mcg/day of folate reduced their risk of developing high blood pressure by almost a third, compared with those who consumed less than 200 mcg/day. Folate also reduced the risk in older women to a lesser degree, reported John P. Forman, M.D., a research and clinical fellow at Brigham and Women's Hospital in Boston.

The most striking effects of folate intake were seen among women aged 35 years or younger, he said. Supplemental folic acid also contributed to this decrease in risk, as most of the women in the higher range of folate intake obtained much of their intake from supplements.

Dr. Forman and colleagues based their findings on data from the Nurses' Health Study (NHS) I, comprising 62,260 women aged 43–70 years, and the NHS II, comprising 93,034 women aged 26–46 years. None of the women had high blood pressure at baseline.

Semiquantitative food-frequency questionnaires were used to gather information about dietary and supplemental folate intake at baseline, and were followed up with additional questionnaires every 4 years. Information about physician-diagnosed high blood pressure was self-reported every 2 years.

Cox regression analysis was used to estimate relative risk after the investigators controlled for age, body mass index, smoking, exercise, family history of hypertension, and intake of alcohol, caffeine, salt, calcium, magnesium, potassium, fiber, methionine, and vitamins B6, B12, and D.

Over 8 years of follow-up, there were 12,347 incident cases of hypertension in NHS I and 7,373 incident cases in NHS II.

Young women who consumed at least 800 mcg/day of folate had a 29% lower risk of high blood pressure than did those who consumed less than 200 mcg/day. Older women who consumed at least 800 mcg/day had a 13% lower risk than did those who consumed less than 200 mcg/day.

There was no significant interaction between age and reduced risk among women in the older cohort when divided into three additional subgroups.

One hypothesis for why the effect of folate varies by age is that the pathogenesis of hypertension may be different in older versus younger women, Dr. Forman said at the meeting, sponsored by the American Heart Association.

The Food and Drug Administration began requiring folate supplementation of several foods, including bread and cereals in 1998. But fortification had begun in 1996, spanning the last 2 years of the NHS I and the last 3 years of the NHS II.

The researchers did not directly measure serum folate, which was a limitation of the study, Dr. Forman said. However, the food-frequency questionnaires used in the cohort have been previously validated and are highly correlated with both dietary records and serum folate levels. Additionally, all of the study participants were registered nurses, and self-reported hypertension was thought to be reliable.

CHICAGO — High folate intake may lower the risk of hypertension, particularly in young women, according to data presented at a conference of the Council for High Blood Pressure Research.

Young women who consumed at least 800 mcg/day of folate reduced their risk of developing high blood pressure by almost a third, compared with those who consumed less than 200 mcg/day. Folate also reduced the risk in older women to a lesser degree, reported John P. Forman, M.D., a research and clinical fellow at Brigham and Women's Hospital in Boston.

The most striking effects of folate intake were seen among women aged 35 years or younger, he said. Supplemental folic acid also contributed to this decrease in risk, as most of the women in the higher range of folate intake obtained much of their intake from supplements.

Dr. Forman and colleagues based their findings on data from the Nurses' Health Study (NHS) I, comprising 62,260 women aged 43–70 years, and the NHS II, comprising 93,034 women aged 26–46 years. None of the women had high blood pressure at baseline.

Semiquantitative food-frequency questionnaires were used to gather information about dietary and supplemental folate intake at baseline, and were followed up with additional questionnaires every 4 years. Information about physician-diagnosed high blood pressure was self-reported every 2 years.

Cox regression analysis was used to estimate relative risk after the investigators controlled for age, body mass index, smoking, exercise, family history of hypertension, and intake of alcohol, caffeine, salt, calcium, magnesium, potassium, fiber, methionine, and vitamins B6, B12, and D.

Over 8 years of follow-up, there were 12,347 incident cases of hypertension in NHS I and 7,373 incident cases in NHS II.

Young women who consumed at least 800 mcg/day of folate had a 29% lower risk of high blood pressure than did those who consumed less than 200 mcg/day. Older women who consumed at least 800 mcg/day had a 13% lower risk than did those who consumed less than 200 mcg/day.

There was no significant interaction between age and reduced risk among women in the older cohort when divided into three additional subgroups.

One hypothesis for why the effect of folate varies by age is that the pathogenesis of hypertension may be different in older versus younger women, Dr. Forman said at the meeting, sponsored by the American Heart Association.

The Food and Drug Administration began requiring folate supplementation of several foods, including bread and cereals in 1998. But fortification had begun in 1996, spanning the last 2 years of the NHS I and the last 3 years of the NHS II.

The researchers did not directly measure serum folate, which was a limitation of the study, Dr. Forman said. However, the food-frequency questionnaires used in the cohort have been previously validated and are highly correlated with both dietary records and serum folate levels. Additionally, all of the study participants were registered nurses, and self-reported hypertension was thought to be reliable.

CHICAGO — High folate intake may lower the risk of hypertension, particularly in young women, according to data presented at a conference of the Council for High Blood Pressure Research.

Young women who consumed at least 800 mcg/day of folate reduced their risk of developing high blood pressure by almost a third, compared with those who consumed less than 200 mcg/day. Folate also reduced the risk in older women to a lesser degree, reported John P. Forman, M.D., a research and clinical fellow at Brigham and Women's Hospital in Boston.

The most striking effects of folate intake were seen among women aged 35 years or younger, he said. Supplemental folic acid also contributed to this decrease in risk, as most of the women in the higher range of folate intake obtained much of their intake from supplements.

Dr. Forman and colleagues based their findings on data from the Nurses' Health Study (NHS) I, comprising 62,260 women aged 43–70 years, and the NHS II, comprising 93,034 women aged 26–46 years. None of the women had high blood pressure at baseline.

Semiquantitative food-frequency questionnaires were used to gather information about dietary and supplemental folate intake at baseline, and were followed up with additional questionnaires every 4 years. Information about physician-diagnosed high blood pressure was self-reported every 2 years.

Cox regression analysis was used to estimate relative risk after the investigators controlled for age, body mass index, smoking, exercise, family history of hypertension, and intake of alcohol, caffeine, salt, calcium, magnesium, potassium, fiber, methionine, and vitamins B6, B12, and D.

Over 8 years of follow-up, there were 12,347 incident cases of hypertension in NHS I and 7,373 incident cases in NHS II.

Young women who consumed at least 800 mcg/day of folate had a 29% lower risk of high blood pressure than did those who consumed less than 200 mcg/day. Older women who consumed at least 800 mcg/day had a 13% lower risk than did those who consumed less than 200 mcg/day.

There was no significant interaction between age and reduced risk among women in the older cohort when divided into three additional subgroups.

One hypothesis for why the effect of folate varies by age is that the pathogenesis of hypertension may be different in older versus younger women, Dr. Forman said at the meeting, sponsored by the American Heart Association.

The Food and Drug Administration began requiring folate supplementation of several foods, including bread and cereals in 1998. But fortification had begun in 1996, spanning the last 2 years of the NHS I and the last 3 years of the NHS II.

The researchers did not directly measure serum folate, which was a limitation of the study, Dr. Forman said. However, the food-frequency questionnaires used in the cohort have been previously validated and are highly correlated with both dietary records and serum folate levels. Additionally, all of the study participants were registered nurses, and self-reported hypertension was thought to be reliable.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

“Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it,” Dr. Altman said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman of the division of rheumatology and arthritis at the University of California, Los Angeles. At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0–4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81).

“I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred during the study, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use. The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

No adverse event reported by the acetaminophen group was considered serious or related to the study drug.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

“Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it,” Dr. Altman said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman of the division of rheumatology and arthritis at the University of California, Los Angeles. At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0–4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81).

“I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred during the study, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use. The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

No adverse event reported by the acetaminophen group was considered serious or related to the study drug.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

“Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it,” Dr. Altman said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman of the division of rheumatology and arthritis at the University of California, Los Angeles. At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0–4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81).

“I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred during the study, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use. The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

No adverse event reported by the acetaminophen group was considered serious or related to the study drug.

CHICAGO — Strengthening the hip abductor muscle may delay progression of medial compartment knee osteoarthritis, according to findings reported at the 2004 World Congress on Osteoarthritis.

The study showed that a greater internal hip abduction moment—or torque generated by the body during walking— protected against medial tibiofemoral osteoarthritis (OA) progression in the ensuing 18 months in patients with knee OA.

Frontal knee mechanics have received most of the attention in knee OA studies. But such studies don't address the issue of stability since few knee muscles specifically provide frontal plane stability, said Alison Chang, a physical therapist at Northwestern University, Chicago.

Instead, hip frontal plane muscles may play a key role in regulating knee load and providing such stability. In addition, “hip muscles have greater cross-sectional area, and can probably generate greater forces or torques,” Ms. Chang explained at the congress, sponsored by the Osteoarthritis Research Society International.

The investigators hypothesized that a decrease in hip abductor muscle torque during walking would lead to an increase in medial tibiofemoral joint loading, and thereby to medial OA progression.

The idea is that during level walking the hip abductor muscles of the stance leg contract to control the slight lowering of the contralateral pelvis. Weakness of the hip abductor muscles in the stance leg may cause an additional drop in the contralateral swing leg. Such a drop would shift the body's center of gravity toward the swing limb, thereby increasing forces across the medial tibiofemoral compartment cartilage of the stance knee, and potentially increasing OA progression.

In the study, conducted in collaboration with Rush University Medical Center in Chicago, 64 patients with mild to moderate OA were evaluated using a motion-capturing system to determine kinematics and kinetic gait parameters at baseline and at 18 months. Inverse dynamics were used to calculate three-dimensional moments at the hip, knee, and ankle joints.

Pain was evaluated using a visual analog scale for each knee. Disease progression was defined as worsening of medial joint space narrowing.

The mean peak internal hip moment was calculated by finding the peak internal hip abduction moments during several gait cycles for each individual and then computing the mean. From these figures, the investigators were able to estimate peak hip abductor muscles activity during the gait cycle.

The mean age of the patients was 66 years, 63% were women, mean body mass index (BMI) was 29, and the mean peak internal hip abduction moment was 4.19% of body weight multiplied by height.

Logistic regression analysis showed that a greater internal hip abduction moment during walking was significantly associated with a reduced likelihood of medial tibiofemoral OA progression at 18 months (odds ratio of 0.63).

This strong protective effect remained after adjustment for age, gender, gait speed, physical activity level, knee pain severity, and knee OA severity (OR 0.52). Further adjustment for ipsilateral hip OA and hip symptoms did not change the odds ratio.

The odds of OA progression were reduced by 50% per additional unit of internal hip abduction moment.

“The results suggest the need for interventional strategies to increase internal hip abduction moments such as hip abductor muscle strengthening in both static and dynamic positions,” Ms. Chang said.

CHICAGO — Strengthening the hip abductor muscle may delay progression of medial compartment knee osteoarthritis, according to findings reported at the 2004 World Congress on Osteoarthritis.

The study showed that a greater internal hip abduction moment—or torque generated by the body during walking— protected against medial tibiofemoral osteoarthritis (OA) progression in the ensuing 18 months in patients with knee OA.

Frontal knee mechanics have received most of the attention in knee OA studies. But such studies don't address the issue of stability since few knee muscles specifically provide frontal plane stability, said Alison Chang, a physical therapist at Northwestern University, Chicago.

Instead, hip frontal plane muscles may play a key role in regulating knee load and providing such stability. In addition, “hip muscles have greater cross-sectional area, and can probably generate greater forces or torques,” Ms. Chang explained at the congress, sponsored by the Osteoarthritis Research Society International.

The investigators hypothesized that a decrease in hip abductor muscle torque during walking would lead to an increase in medial tibiofemoral joint loading, and thereby to medial OA progression.

The idea is that during level walking the hip abductor muscles of the stance leg contract to control the slight lowering of the contralateral pelvis. Weakness of the hip abductor muscles in the stance leg may cause an additional drop in the contralateral swing leg. Such a drop would shift the body's center of gravity toward the swing limb, thereby increasing forces across the medial tibiofemoral compartment cartilage of the stance knee, and potentially increasing OA progression.

In the study, conducted in collaboration with Rush University Medical Center in Chicago, 64 patients with mild to moderate OA were evaluated using a motion-capturing system to determine kinematics and kinetic gait parameters at baseline and at 18 months. Inverse dynamics were used to calculate three-dimensional moments at the hip, knee, and ankle joints.

Pain was evaluated using a visual analog scale for each knee. Disease progression was defined as worsening of medial joint space narrowing.

The mean peak internal hip moment was calculated by finding the peak internal hip abduction moments during several gait cycles for each individual and then computing the mean. From these figures, the investigators were able to estimate peak hip abductor muscles activity during the gait cycle.

The mean age of the patients was 66 years, 63% were women, mean body mass index (BMI) was 29, and the mean peak internal hip abduction moment was 4.19% of body weight multiplied by height.

Logistic regression analysis showed that a greater internal hip abduction moment during walking was significantly associated with a reduced likelihood of medial tibiofemoral OA progression at 18 months (odds ratio of 0.63).

This strong protective effect remained after adjustment for age, gender, gait speed, physical activity level, knee pain severity, and knee OA severity (OR 0.52). Further adjustment for ipsilateral hip OA and hip symptoms did not change the odds ratio.

The odds of OA progression were reduced by 50% per additional unit of internal hip abduction moment.

“The results suggest the need for interventional strategies to increase internal hip abduction moments such as hip abductor muscle strengthening in both static and dynamic positions,” Ms. Chang said.

CHICAGO — Strengthening the hip abductor muscle may delay progression of medial compartment knee osteoarthritis, according to findings reported at the 2004 World Congress on Osteoarthritis.

The study showed that a greater internal hip abduction moment—or torque generated by the body during walking— protected against medial tibiofemoral osteoarthritis (OA) progression in the ensuing 18 months in patients with knee OA.

Frontal knee mechanics have received most of the attention in knee OA studies. But such studies don't address the issue of stability since few knee muscles specifically provide frontal plane stability, said Alison Chang, a physical therapist at Northwestern University, Chicago.

Instead, hip frontal plane muscles may play a key role in regulating knee load and providing such stability. In addition, “hip muscles have greater cross-sectional area, and can probably generate greater forces or torques,” Ms. Chang explained at the congress, sponsored by the Osteoarthritis Research Society International.

The investigators hypothesized that a decrease in hip abductor muscle torque during walking would lead to an increase in medial tibiofemoral joint loading, and thereby to medial OA progression.

The idea is that during level walking the hip abductor muscles of the stance leg contract to control the slight lowering of the contralateral pelvis. Weakness of the hip abductor muscles in the stance leg may cause an additional drop in the contralateral swing leg. Such a drop would shift the body's center of gravity toward the swing limb, thereby increasing forces across the medial tibiofemoral compartment cartilage of the stance knee, and potentially increasing OA progression.

In the study, conducted in collaboration with Rush University Medical Center in Chicago, 64 patients with mild to moderate OA were evaluated using a motion-capturing system to determine kinematics and kinetic gait parameters at baseline and at 18 months. Inverse dynamics were used to calculate three-dimensional moments at the hip, knee, and ankle joints.

Pain was evaluated using a visual analog scale for each knee. Disease progression was defined as worsening of medial joint space narrowing.

The mean peak internal hip moment was calculated by finding the peak internal hip abduction moments during several gait cycles for each individual and then computing the mean. From these figures, the investigators were able to estimate peak hip abductor muscles activity during the gait cycle.

The mean age of the patients was 66 years, 63% were women, mean body mass index (BMI) was 29, and the mean peak internal hip abduction moment was 4.19% of body weight multiplied by height.

Logistic regression analysis showed that a greater internal hip abduction moment during walking was significantly associated with a reduced likelihood of medial tibiofemoral OA progression at 18 months (odds ratio of 0.63).

This strong protective effect remained after adjustment for age, gender, gait speed, physical activity level, knee pain severity, and knee OA severity (OR 0.52). Further adjustment for ipsilateral hip OA and hip symptoms did not change the odds ratio.

The odds of OA progression were reduced by 50% per additional unit of internal hip abduction moment.

“The results suggest the need for interventional strategies to increase internal hip abduction moments such as hip abductor muscle strengthening in both static and dynamic positions,” Ms. Chang said.

CHICAGO — Long-term use of 5% lidocaine ointment shows promise as a treatment for the management of vulvar vestibulitis, vaginal apex pain, and intrinsic cervical pain, John Steege, M.D., said at a meeting sponsored by the International Pelvic Pain Society.

“We started out with vestibulitis pain and moved on to vaginal apex pain, and overnight lidocaine works pretty well,” said Dr. Steege of the division of advanced laparoscopic and gynecologic surgery at the University of North Carolina, Chapel Hill. “We've done 52 vaginal apex revisions, but we've slowed down on that in the last few years because the overnight lidocaine works pretty well.”

Dr. Steege credits colleague Dennis Zolnoun, M.D., of the department of ob.gyn. at the university, for the thinking behind the treatment. In a small study last year, Dr. Zolnoun and colleagues treated 61 women who presented with introital pain and met the criteria for vulvar vestibulitis.

After a mean of 7 weeks of nightly treatment with 5% lidocaine ointment, 76% of women reported the ability to have intercourse, compared with 36% before treatment. Intercourse-related pain score was 39 points on a 100-mm visual analog scale after treatment, with a decrease of 10 points in daily pain score.

They found no association between the response to nightly treatment with lidocaine ointment and prior episodic use of lidocaine.

Dr. Steege said the treatment has evolved from a nightly application of lidocaine ointment to a three-times-daily application. Topical estrogen also is sometimes added.

Some patients with intrinsic cervical pain are treated with 5% lidocaine using a diaphragm. In these patients, “the cervix looks fine, but if you take a [cotton swab] and walk it around the cervix, at 3 o'clock it hurts; sometimes after deliveries, but sometimes it's plain out of the blue,” Dr. Steege said. “Have them use a diaphragm with a little lidocaine jelly in it overnight and keep it anesthetized for 8 hours out of the day, and a fair amount get better. You're treating it like a neuropathic pain.”

Dr. Steege said that changes in the last 20 years in the way pelvic pain is viewed, as well as cross talk between disciplines, have opened new avenues for the clinical treatment of pelvic pain. This includes using local anesthetics whenever possible together with physical therapy techniques and medications aimed at peripheral somatic changes and central changes, respectively.

CHICAGO — Long-term use of 5% lidocaine ointment shows promise as a treatment for the management of vulvar vestibulitis, vaginal apex pain, and intrinsic cervical pain, John Steege, M.D., said at a meeting sponsored by the International Pelvic Pain Society.

“We started out with vestibulitis pain and moved on to vaginal apex pain, and overnight lidocaine works pretty well,” said Dr. Steege of the division of advanced laparoscopic and gynecologic surgery at the University of North Carolina, Chapel Hill. “We've done 52 vaginal apex revisions, but we've slowed down on that in the last few years because the overnight lidocaine works pretty well.”

Dr. Steege credits colleague Dennis Zolnoun, M.D., of the department of ob.gyn. at the university, for the thinking behind the treatment. In a small study last year, Dr. Zolnoun and colleagues treated 61 women who presented with introital pain and met the criteria for vulvar vestibulitis.

After a mean of 7 weeks of nightly treatment with 5% lidocaine ointment, 76% of women reported the ability to have intercourse, compared with 36% before treatment. Intercourse-related pain score was 39 points on a 100-mm visual analog scale after treatment, with a decrease of 10 points in daily pain score.

They found no association between the response to nightly treatment with lidocaine ointment and prior episodic use of lidocaine.

Dr. Steege said the treatment has evolved from a nightly application of lidocaine ointment to a three-times-daily application. Topical estrogen also is sometimes added.

Some patients with intrinsic cervical pain are treated with 5% lidocaine using a diaphragm. In these patients, “the cervix looks fine, but if you take a [cotton swab] and walk it around the cervix, at 3 o'clock it hurts; sometimes after deliveries, but sometimes it's plain out of the blue,” Dr. Steege said. “Have them use a diaphragm with a little lidocaine jelly in it overnight and keep it anesthetized for 8 hours out of the day, and a fair amount get better. You're treating it like a neuropathic pain.”

Dr. Steege said that changes in the last 20 years in the way pelvic pain is viewed, as well as cross talk between disciplines, have opened new avenues for the clinical treatment of pelvic pain. This includes using local anesthetics whenever possible together with physical therapy techniques and medications aimed at peripheral somatic changes and central changes, respectively.

CHICAGO — Long-term use of 5% lidocaine ointment shows promise as a treatment for the management of vulvar vestibulitis, vaginal apex pain, and intrinsic cervical pain, John Steege, M.D., said at a meeting sponsored by the International Pelvic Pain Society.

“We started out with vestibulitis pain and moved on to vaginal apex pain, and overnight lidocaine works pretty well,” said Dr. Steege of the division of advanced laparoscopic and gynecologic surgery at the University of North Carolina, Chapel Hill. “We've done 52 vaginal apex revisions, but we've slowed down on that in the last few years because the overnight lidocaine works pretty well.”

Dr. Steege credits colleague Dennis Zolnoun, M.D., of the department of ob.gyn. at the university, for the thinking behind the treatment. In a small study last year, Dr. Zolnoun and colleagues treated 61 women who presented with introital pain and met the criteria for vulvar vestibulitis.

After a mean of 7 weeks of nightly treatment with 5% lidocaine ointment, 76% of women reported the ability to have intercourse, compared with 36% before treatment. Intercourse-related pain score was 39 points on a 100-mm visual analog scale after treatment, with a decrease of 10 points in daily pain score.

They found no association between the response to nightly treatment with lidocaine ointment and prior episodic use of lidocaine.

Dr. Steege said the treatment has evolved from a nightly application of lidocaine ointment to a three-times-daily application. Topical estrogen also is sometimes added.

Some patients with intrinsic cervical pain are treated with 5% lidocaine using a diaphragm. In these patients, “the cervix looks fine, but if you take a [cotton swab] and walk it around the cervix, at 3 o'clock it hurts; sometimes after deliveries, but sometimes it's plain out of the blue,” Dr. Steege said. “Have them use a diaphragm with a little lidocaine jelly in it overnight and keep it anesthetized for 8 hours out of the day, and a fair amount get better. You're treating it like a neuropathic pain.”

Dr. Steege said that changes in the last 20 years in the way pelvic pain is viewed, as well as cross talk between disciplines, have opened new avenues for the clinical treatment of pelvic pain. This includes using local anesthetics whenever possible together with physical therapy techniques and medications aimed at peripheral somatic changes and central changes, respectively.

CHICAGO — A long-acting formulation of dexmethylphenidate is safe and effective in children and adolescents with attention-deficit hyperactivity disorder, according to data presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Children taking the investigational treatment showed improvements in core symptoms both at school and at home, compared with patients taking placebo.

The treatment, currently known as dexmethylphenidate extended-release capsules (d-MPH-ER), is a once-daily formulation of Focalin, which was introduced in 2002. D-MPH-ER is in phase III trials.

Focalin and d-MPH-ER contain only the active isomer of racemic methylphenidate (Ritalin), said lead investigator Frank Lopez, M.D., of Children's Developmental Center, Maitland, Fla. “You get twice the effect at half the amount in terms of what you are delivering,” Dr. Lopez said during the poster presentation.

Sustained medications are often preferable to immediate-release drugs because they improve compliance and decrease the stigma of having to take medications at school.

In the double-blind, parallel-group study, 103 patients (aged 6–17 years) with a previous diagnosis of ADHD of any type were randomized to receive d-MPH-ER 5–30 mg or placebo once daily for 7 weeks. A flexible dosing schedule was used during weeks 1 through 5 to determine optimal therapeutic levels, and patients were then maintained on their optimal dosages for the remaining 2 weeks.

A total of 97 patients were evaluated for efficacy, and a total of 100 patients were evaluated for safety, he said. The primary efficacy end point was change from baseline to final visit in the total subscale score of the Conners ADHD/DSM-IV Scale for Teachers (CADS-T).

At the final visit, scores on all primary and secondary efficacy end points, except the Child Health Questionnaire physical component score, were statistically superior for d-MPH-ER, compared with placebo. The differences between groups emerged early and increased over time.

The adjusted mean change from baseline to final visit in the CADS-T total score was 16.3 in the d-MPH-ER group vs. 5.7 in the placebo group. The adjusted mean change in the CADS for Parents (CADS-P) total subscale scores from baseline was 17.6 in the d-MPH-ER group vs. 6.5 in the placebo group.

Overall, 67% of patients treated with d-MPH-ER were rated as “very much improved” or “much improved” on the Clinical Global Impressions-Improvement (CGI-I) scale at the final visit, compared with 13% of patients in the placebo group.

Of d-MPH-ER patients, 49% reported an adverse event, compared with 26% in the placebo group. The most frequently reported adverse events associated with d-MPH-ER were decreased appetite (28%), headache (9%), and insomnia (7%).

CHICAGO — A long-acting formulation of dexmethylphenidate is safe and effective in children and adolescents with attention-deficit hyperactivity disorder, according to data presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Children taking the investigational treatment showed improvements in core symptoms both at school and at home, compared with patients taking placebo.

The treatment, currently known as dexmethylphenidate extended-release capsules (d-MPH-ER), is a once-daily formulation of Focalin, which was introduced in 2002. D-MPH-ER is in phase III trials.

Focalin and d-MPH-ER contain only the active isomer of racemic methylphenidate (Ritalin), said lead investigator Frank Lopez, M.D., of Children's Developmental Center, Maitland, Fla. “You get twice the effect at half the amount in terms of what you are delivering,” Dr. Lopez said during the poster presentation.

Sustained medications are often preferable to immediate-release drugs because they improve compliance and decrease the stigma of having to take medications at school.

In the double-blind, parallel-group study, 103 patients (aged 6–17 years) with a previous diagnosis of ADHD of any type were randomized to receive d-MPH-ER 5–30 mg or placebo once daily for 7 weeks. A flexible dosing schedule was used during weeks 1 through 5 to determine optimal therapeutic levels, and patients were then maintained on their optimal dosages for the remaining 2 weeks.

A total of 97 patients were evaluated for efficacy, and a total of 100 patients were evaluated for safety, he said. The primary efficacy end point was change from baseline to final visit in the total subscale score of the Conners ADHD/DSM-IV Scale for Teachers (CADS-T).

At the final visit, scores on all primary and secondary efficacy end points, except the Child Health Questionnaire physical component score, were statistically superior for d-MPH-ER, compared with placebo. The differences between groups emerged early and increased over time.

The adjusted mean change from baseline to final visit in the CADS-T total score was 16.3 in the d-MPH-ER group vs. 5.7 in the placebo group. The adjusted mean change in the CADS for Parents (CADS-P) total subscale scores from baseline was 17.6 in the d-MPH-ER group vs. 6.5 in the placebo group.

Overall, 67% of patients treated with d-MPH-ER were rated as “very much improved” or “much improved” on the Clinical Global Impressions-Improvement (CGI-I) scale at the final visit, compared with 13% of patients in the placebo group.

Of d-MPH-ER patients, 49% reported an adverse event, compared with 26% in the placebo group. The most frequently reported adverse events associated with d-MPH-ER were decreased appetite (28%), headache (9%), and insomnia (7%).

CHICAGO — A long-acting formulation of dexmethylphenidate is safe and effective in children and adolescents with attention-deficit hyperactivity disorder, according to data presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Children taking the investigational treatment showed improvements in core symptoms both at school and at home, compared with patients taking placebo.

The treatment, currently known as dexmethylphenidate extended-release capsules (d-MPH-ER), is a once-daily formulation of Focalin, which was introduced in 2002. D-MPH-ER is in phase III trials.

Focalin and d-MPH-ER contain only the active isomer of racemic methylphenidate (Ritalin), said lead investigator Frank Lopez, M.D., of Children's Developmental Center, Maitland, Fla. “You get twice the effect at half the amount in terms of what you are delivering,” Dr. Lopez said during the poster presentation.

Sustained medications are often preferable to immediate-release drugs because they improve compliance and decrease the stigma of having to take medications at school.

In the double-blind, parallel-group study, 103 patients (aged 6–17 years) with a previous diagnosis of ADHD of any type were randomized to receive d-MPH-ER 5–30 mg or placebo once daily for 7 weeks. A flexible dosing schedule was used during weeks 1 through 5 to determine optimal therapeutic levels, and patients were then maintained on their optimal dosages for the remaining 2 weeks.

A total of 97 patients were evaluated for efficacy, and a total of 100 patients were evaluated for safety, he said. The primary efficacy end point was change from baseline to final visit in the total subscale score of the Conners ADHD/DSM-IV Scale for Teachers (CADS-T).

At the final visit, scores on all primary and secondary efficacy end points, except the Child Health Questionnaire physical component score, were statistically superior for d-MPH-ER, compared with placebo. The differences between groups emerged early and increased over time.

The adjusted mean change from baseline to final visit in the CADS-T total score was 16.3 in the d-MPH-ER group vs. 5.7 in the placebo group. The adjusted mean change in the CADS for Parents (CADS-P) total subscale scores from baseline was 17.6 in the d-MPH-ER group vs. 6.5 in the placebo group.

Overall, 67% of patients treated with d-MPH-ER were rated as “very much improved” or “much improved” on the Clinical Global Impressions-Improvement (CGI-I) scale at the final visit, compared with 13% of patients in the placebo group.

Of d-MPH-ER patients, 49% reported an adverse event, compared with 26% in the placebo group. The most frequently reported adverse events associated with d-MPH-ER were decreased appetite (28%), headache (9%), and insomnia (7%).

CHICAGO — For the first time, researchers have shown that reducing salt intake can protect against aldosterone-induced reduction in blood vessel flexibility in patients with resistant hypertension.

The research also suggests that measuring urinary aldosterone and sodium may help predict cardiovascular risk in patients with resistant hypertension, David A. Calhoun, M.D., reported in a poster presentation at a conference of the Council for High Blood Pressure Research.

In a study of 120 consecutive patients with resistant hypertension (uncontrolled by three or more medications) whose dietary salt intake was not restricted, Dr. Calhoun and colleagues prospectively evaluated plasma renin activity and 24-hour urinary aldosterone and sodium excretion.

Brachial artery flow-mediated dilation (FMD) also was measured prospectively in all patients by using high-resolution ultrasound. The ability of an artery to relax and expand in response to increases in blood flow is a sign of a flexible artery with a healthy endothelium. FMD is the percentage of change in vessel diameter after a tourniquet placed on the forearm is released.

Aldosteronism, defined as suppressed plasma renin activity less than 1.0 ng/mL per hour and elevated aldosterone excretion, defined as greater than 12 mcg/24 hours, was found in 34 patients, said Dr. Calhoun of the vascular biology and hypertension program at the University of Alabama, Birmingham.

In the aldosteronism patients, there was a strong negative correlation between FMD and urinary sodium excretion (correlation coefficient -0.39), as well as the product of urinary aldosterone and sodium (correlation coefficient -0.46), consistent with better endothelial function in patients eating a lower-sodium diet.

The patients were divided into low- or high-sodium groups based on urinary sodium excretion of less than or greater than 150 meq/L per day. Mean FMD was higher in the 10 patients with low urinary sodium excretion than in the 24 patients with a high sodium excretion (2.6% vs. 1.6%, respectively). The groups were similar in age, body mass index, mean blood pressure, medication use, and aldosterone excretion.

In the five patients with very low sodium excretion (less than 100 meq/L per day), FMD was even higher (3.4%). This is consistent with a dose-dependent relation between sodium excretion and endothelial function, Dr. Calhoun concluded at the meeting, sponsored by the American Heart Association.

CHICAGO — For the first time, researchers have shown that reducing salt intake can protect against aldosterone-induced reduction in blood vessel flexibility in patients with resistant hypertension.

The research also suggests that measuring urinary aldosterone and sodium may help predict cardiovascular risk in patients with resistant hypertension, David A. Calhoun, M.D., reported in a poster presentation at a conference of the Council for High Blood Pressure Research.

In a study of 120 consecutive patients with resistant hypertension (uncontrolled by three or more medications) whose dietary salt intake was not restricted, Dr. Calhoun and colleagues prospectively evaluated plasma renin activity and 24-hour urinary aldosterone and sodium excretion.

Brachial artery flow-mediated dilation (FMD) also was measured prospectively in all patients by using high-resolution ultrasound. The ability of an artery to relax and expand in response to increases in blood flow is a sign of a flexible artery with a healthy endothelium. FMD is the percentage of change in vessel diameter after a tourniquet placed on the forearm is released.

Aldosteronism, defined as suppressed plasma renin activity less than 1.0 ng/mL per hour and elevated aldosterone excretion, defined as greater than 12 mcg/24 hours, was found in 34 patients, said Dr. Calhoun of the vascular biology and hypertension program at the University of Alabama, Birmingham.

In the aldosteronism patients, there was a strong negative correlation between FMD and urinary sodium excretion (correlation coefficient -0.39), as well as the product of urinary aldosterone and sodium (correlation coefficient -0.46), consistent with better endothelial function in patients eating a lower-sodium diet.

The patients were divided into low- or high-sodium groups based on urinary sodium excretion of less than or greater than 150 meq/L per day. Mean FMD was higher in the 10 patients with low urinary sodium excretion than in the 24 patients with a high sodium excretion (2.6% vs. 1.6%, respectively). The groups were similar in age, body mass index, mean blood pressure, medication use, and aldosterone excretion.

In the five patients with very low sodium excretion (less than 100 meq/L per day), FMD was even higher (3.4%). This is consistent with a dose-dependent relation between sodium excretion and endothelial function, Dr. Calhoun concluded at the meeting, sponsored by the American Heart Association.

CHICAGO — For the first time, researchers have shown that reducing salt intake can protect against aldosterone-induced reduction in blood vessel flexibility in patients with resistant hypertension.

The research also suggests that measuring urinary aldosterone and sodium may help predict cardiovascular risk in patients with resistant hypertension, David A. Calhoun, M.D., reported in a poster presentation at a conference of the Council for High Blood Pressure Research.

In a study of 120 consecutive patients with resistant hypertension (uncontrolled by three or more medications) whose dietary salt intake was not restricted, Dr. Calhoun and colleagues prospectively evaluated plasma renin activity and 24-hour urinary aldosterone and sodium excretion.

Brachial artery flow-mediated dilation (FMD) also was measured prospectively in all patients by using high-resolution ultrasound. The ability of an artery to relax and expand in response to increases in blood flow is a sign of a flexible artery with a healthy endothelium. FMD is the percentage of change in vessel diameter after a tourniquet placed on the forearm is released.

Aldosteronism, defined as suppressed plasma renin activity less than 1.0 ng/mL per hour and elevated aldosterone excretion, defined as greater than 12 mcg/24 hours, was found in 34 patients, said Dr. Calhoun of the vascular biology and hypertension program at the University of Alabama, Birmingham.

In the aldosteronism patients, there was a strong negative correlation between FMD and urinary sodium excretion (correlation coefficient -0.39), as well as the product of urinary aldosterone and sodium (correlation coefficient -0.46), consistent with better endothelial function in patients eating a lower-sodium diet.

The patients were divided into low- or high-sodium groups based on urinary sodium excretion of less than or greater than 150 meq/L per day. Mean FMD was higher in the 10 patients with low urinary sodium excretion than in the 24 patients with a high sodium excretion (2.6% vs. 1.6%, respectively). The groups were similar in age, body mass index, mean blood pressure, medication use, and aldosterone excretion.

In the five patients with very low sodium excretion (less than 100 meq/L per day), FMD was even higher (3.4%). This is consistent with a dose-dependent relation between sodium excretion and endothelial function, Dr. Calhoun concluded at the meeting, sponsored by the American Heart Association.

TORONTO — Interim data suggest that oxypurinol, a xanthine oxidase inhibitor, significantly increased left ventricular ejection fractions in patients with heart failure after just 4 weeks, Joshua Hare, M.D., reported at the annual meeting of the Heart Failure Society of America.

These are early and provocative data, but they are early human data with the chronic use of oxypurinol, “and I think it's very exciting,” Dr. Hare said.

Dr. Hare, director of the heart failure/cardiac transplant program at Johns Hopkins University in Baltimore, is a consultant for and has a financial interest in Cardiome Pharma Corp., which is developing the drug.

Xanthine oxidase is upregulated in heart failure, and is clearly a source of oxidative stress, Dr. Hare said. Targeting xanthine oxidase represents a potential new treatment strategy for patients with heart failure.

Oxypurinol is the active metabolite of allopurinol, a drug that has been used since the early 1960s to suppress uric acid formation in patients with gout. Initial clinical results in nine patients with heart failure showed that allopurinol improved cardiac mechanical efficiency by 40% and cardiac pressure efficiency by 22%.

Oxypurinol may improve myocardial contractility by increasing sensitization of the cardiac myofilaments to calcium. Moreover, it may do so without increasing myocardial oxygen consumption. Most inotropic drugs improve myocardial contractility, but they also increase myocardial oxygen consumption, which worsens the myocardial ischemia and possibly leads to arrhythmias.

“We've traditionally thought of oxidative stress as something that destroys cell membranes and proteins, but as we are clearly uncovering now, there is a critical role for free radicals in nitric oxide and signaling,” Dr. Hare said. “And it may be this signaling element that is the target of our therapy.”

In a trial conducted in Argentina, 48 patients with heart failure were enrolled in a phase II, proof-of-principle study, and randomized to placebo or 600 mg of oxypurinol daily added to best conventional therapy for 4 weeks.

Interim data from the trial, led by Horatio Cingolani, M.D., of the National University of La Plata (Argentina), showed that left ventricular ejection fractions significantly increased from 35% to 38% in the oxypurinol group and decreased from 30% to 29% from baseline in the placebo group. There was no statistical difference in 6-minute walk scores from baseline between the two groups.

Two ongoing studies should be completed this year, including a phase II trial of oxypurinol infusions in patients with heart failure of ischemic etiology and a 24-week, phase II/III trial of oral oxypurinol in 400 patients with heart failure.

TORONTO — Interim data suggest that oxypurinol, a xanthine oxidase inhibitor, significantly increased left ventricular ejection fractions in patients with heart failure after just 4 weeks, Joshua Hare, M.D., reported at the annual meeting of the Heart Failure Society of America.

These are early and provocative data, but they are early human data with the chronic use of oxypurinol, “and I think it's very exciting,” Dr. Hare said.

Dr. Hare, director of the heart failure/cardiac transplant program at Johns Hopkins University in Baltimore, is a consultant for and has a financial interest in Cardiome Pharma Corp., which is developing the drug.

Xanthine oxidase is upregulated in heart failure, and is clearly a source of oxidative stress, Dr. Hare said. Targeting xanthine oxidase represents a potential new treatment strategy for patients with heart failure.

Oxypurinol is the active metabolite of allopurinol, a drug that has been used since the early 1960s to suppress uric acid formation in patients with gout. Initial clinical results in nine patients with heart failure showed that allopurinol improved cardiac mechanical efficiency by 40% and cardiac pressure efficiency by 22%.

Oxypurinol may improve myocardial contractility by increasing sensitization of the cardiac myofilaments to calcium. Moreover, it may do so without increasing myocardial oxygen consumption. Most inotropic drugs improve myocardial contractility, but they also increase myocardial oxygen consumption, which worsens the myocardial ischemia and possibly leads to arrhythmias.

“We've traditionally thought of oxidative stress as something that destroys cell membranes and proteins, but as we are clearly uncovering now, there is a critical role for free radicals in nitric oxide and signaling,” Dr. Hare said. “And it may be this signaling element that is the target of our therapy.”

In a trial conducted in Argentina, 48 patients with heart failure were enrolled in a phase II, proof-of-principle study, and randomized to placebo or 600 mg of oxypurinol daily added to best conventional therapy for 4 weeks.

Interim data from the trial, led by Horatio Cingolani, M.D., of the National University of La Plata (Argentina), showed that left ventricular ejection fractions significantly increased from 35% to 38% in the oxypurinol group and decreased from 30% to 29% from baseline in the placebo group. There was no statistical difference in 6-minute walk scores from baseline between the two groups.

Two ongoing studies should be completed this year, including a phase II trial of oxypurinol infusions in patients with heart failure of ischemic etiology and a 24-week, phase II/III trial of oral oxypurinol in 400 patients with heart failure.

TORONTO — Interim data suggest that oxypurinol, a xanthine oxidase inhibitor, significantly increased left ventricular ejection fractions in patients with heart failure after just 4 weeks, Joshua Hare, M.D., reported at the annual meeting of the Heart Failure Society of America.

These are early and provocative data, but they are early human data with the chronic use of oxypurinol, “and I think it's very exciting,” Dr. Hare said.

Dr. Hare, director of the heart failure/cardiac transplant program at Johns Hopkins University in Baltimore, is a consultant for and has a financial interest in Cardiome Pharma Corp., which is developing the drug.

Xanthine oxidase is upregulated in heart failure, and is clearly a source of oxidative stress, Dr. Hare said. Targeting xanthine oxidase represents a potential new treatment strategy for patients with heart failure.

Oxypurinol is the active metabolite of allopurinol, a drug that has been used since the early 1960s to suppress uric acid formation in patients with gout. Initial clinical results in nine patients with heart failure showed that allopurinol improved cardiac mechanical efficiency by 40% and cardiac pressure efficiency by 22%.

Oxypurinol may improve myocardial contractility by increasing sensitization of the cardiac myofilaments to calcium. Moreover, it may do so without increasing myocardial oxygen consumption. Most inotropic drugs improve myocardial contractility, but they also increase myocardial oxygen consumption, which worsens the myocardial ischemia and possibly leads to arrhythmias.

“We've traditionally thought of oxidative stress as something that destroys cell membranes and proteins, but as we are clearly uncovering now, there is a critical role for free radicals in nitric oxide and signaling,” Dr. Hare said. “And it may be this signaling element that is the target of our therapy.”

In a trial conducted in Argentina, 48 patients with heart failure were enrolled in a phase II, proof-of-principle study, and randomized to placebo or 600 mg of oxypurinol daily added to best conventional therapy for 4 weeks.

Interim data from the trial, led by Horatio Cingolani, M.D., of the National University of La Plata (Argentina), showed that left ventricular ejection fractions significantly increased from 35% to 38% in the oxypurinol group and decreased from 30% to 29% from baseline in the placebo group. There was no statistical difference in 6-minute walk scores from baseline between the two groups.

Two ongoing studies should be completed this year, including a phase II trial of oxypurinol infusions in patients with heart failure of ischemic etiology and a 24-week, phase II/III trial of oral oxypurinol in 400 patients with heart failure.

CHICAGO — An herbal remedy made from a subspecies of rose hip (Rosa canina) significantly reduced pain in patients with osteoarthritis of the hand, compared with placebo, according to the results of a small, randomized controlled study.

The 32 patients in the study had osteoarthritis of at least one joint of the hand and were randomized to treatment with either five capsules of 0.5 g standardized rose hip powder or identical placebo twice daily for 3 months, after which the study arms were switched and patients took the alternative treatment for an additional 3 months.

During the two treatment periods, 88% of patients taking active treatment reported a reduction in pain, compared with 36% of those taking placebo, Kaj. Winther, M.D., said in a poster presentation at the 2004 World Congress on Osteoarthritis. C-reactive protein (CRP) levels also fell with active treatment.

Dr. Winther and his and colleagues at University Hospital Rigshospitalet in Copenhagen began looking for an alternative pain medication for his elderly patients with cardiovascular disease and thrombosis who also suffered from osteoarthritis.

“Nonsteroidals, aspirin, Cox-2 [inhibitors], etc., all had their side effects, and did not go well with warfarin,” Dr. Winther said at the congress, sponsored by the Osteoarthritis Research Society International.

In the current study, before and after each of the two treatment periods, patients evaluated their pain and stiffness while performing 1 of 15 different daily activities.

A 10-point scale was used to evaluate their pain, with a score of 10 being the most severe pain.

The mean age was 62 years, 28 patients were female, and all had a positive handgrip test. Eight patients were taking NSAIDs, 16 patients regularly took acetaminophen.

Taking the mean of all 15 activity scores, pain was significantly reduced while on active treatment, compared with placebo (4.8 vs. 5.3, respectively).

Evaluation of stiffness showed a similar pattern of improvement (4.6 active treatment vs. 5.1 placebo).

The overall feeling of discomfort from the disease was significantly reduced from 5.8 at baseline to 4.6 while on active treatment, compared with 5.7 and 5.5 for the placebo group.

The treatment with LitoZin, the formulation used in the study, was associated with significant decreases in serum C-reactive protein levels below baseline levels (P value of less than .05). CRP levels fell from a range of 4-23 mg/L at baseline to a range of 3.8-16 mg/L after treatment.

LitoZin, which is manufactured by Dansk Droge Ltd., Ishøj, Denmark, and distributed in Europe, is expected to be marketed in 2005 in the United States by EuroPharma Inc., Green Bay, Wis.

Side effects were comparable with placebo, and no patients dropped out of the study, reported Dr. Winther.

Dr. Winther disclosed that he has no financial interest in the product.

CHICAGO — An herbal remedy made from a subspecies of rose hip (Rosa canina) significantly reduced pain in patients with osteoarthritis of the hand, compared with placebo, according to the results of a small, randomized controlled study.

The 32 patients in the study had osteoarthritis of at least one joint of the hand and were randomized to treatment with either five capsules of 0.5 g standardized rose hip powder or identical placebo twice daily for 3 months, after which the study arms were switched and patients took the alternative treatment for an additional 3 months.

During the two treatment periods, 88% of patients taking active treatment reported a reduction in pain, compared with 36% of those taking placebo, Kaj. Winther, M.D., said in a poster presentation at the 2004 World Congress on Osteoarthritis. C-reactive protein (CRP) levels also fell with active treatment.

Dr. Winther and his and colleagues at University Hospital Rigshospitalet in Copenhagen began looking for an alternative pain medication for his elderly patients with cardiovascular disease and thrombosis who also suffered from osteoarthritis.

“Nonsteroidals, aspirin, Cox-2 [inhibitors], etc., all had their side effects, and did not go well with warfarin,” Dr. Winther said at the congress, sponsored by the Osteoarthritis Research Society International.

In the current study, before and after each of the two treatment periods, patients evaluated their pain and stiffness while performing 1 of 15 different daily activities.

A 10-point scale was used to evaluate their pain, with a score of 10 being the most severe pain.

The mean age was 62 years, 28 patients were female, and all had a positive handgrip test. Eight patients were taking NSAIDs, 16 patients regularly took acetaminophen.

Taking the mean of all 15 activity scores, pain was significantly reduced while on active treatment, compared with placebo (4.8 vs. 5.3, respectively).

Evaluation of stiffness showed a similar pattern of improvement (4.6 active treatment vs. 5.1 placebo).

The overall feeling of discomfort from the disease was significantly reduced from 5.8 at baseline to 4.6 while on active treatment, compared with 5.7 and 5.5 for the placebo group.

The treatment with LitoZin, the formulation used in the study, was associated with significant decreases in serum C-reactive protein levels below baseline levels (P value of less than .05). CRP levels fell from a range of 4-23 mg/L at baseline to a range of 3.8-16 mg/L after treatment.

LitoZin, which is manufactured by Dansk Droge Ltd., Ishøj, Denmark, and distributed in Europe, is expected to be marketed in 2005 in the United States by EuroPharma Inc., Green Bay, Wis.

Side effects were comparable with placebo, and no patients dropped out of the study, reported Dr. Winther.

Dr. Winther disclosed that he has no financial interest in the product.

CHICAGO — An herbal remedy made from a subspecies of rose hip (Rosa canina) significantly reduced pain in patients with osteoarthritis of the hand, compared with placebo, according to the results of a small, randomized controlled study.

The 32 patients in the study had osteoarthritis of at least one joint of the hand and were randomized to treatment with either five capsules of 0.5 g standardized rose hip powder or identical placebo twice daily for 3 months, after which the study arms were switched and patients took the alternative treatment for an additional 3 months.

During the two treatment periods, 88% of patients taking active treatment reported a reduction in pain, compared with 36% of those taking placebo, Kaj. Winther, M.D., said in a poster presentation at the 2004 World Congress on Osteoarthritis. C-reactive protein (CRP) levels also fell with active treatment.

Dr. Winther and his and colleagues at University Hospital Rigshospitalet in Copenhagen began looking for an alternative pain medication for his elderly patients with cardiovascular disease and thrombosis who also suffered from osteoarthritis.

“Nonsteroidals, aspirin, Cox-2 [inhibitors], etc., all had their side effects, and did not go well with warfarin,” Dr. Winther said at the congress, sponsored by the Osteoarthritis Research Society International.

In the current study, before and after each of the two treatment periods, patients evaluated their pain and stiffness while performing 1 of 15 different daily activities.

A 10-point scale was used to evaluate their pain, with a score of 10 being the most severe pain.

The mean age was 62 years, 28 patients were female, and all had a positive handgrip test. Eight patients were taking NSAIDs, 16 patients regularly took acetaminophen.

Taking the mean of all 15 activity scores, pain was significantly reduced while on active treatment, compared with placebo (4.8 vs. 5.3, respectively).

Evaluation of stiffness showed a similar pattern of improvement (4.6 active treatment vs. 5.1 placebo).

The overall feeling of discomfort from the disease was significantly reduced from 5.8 at baseline to 4.6 while on active treatment, compared with 5.7 and 5.5 for the placebo group.

The treatment with LitoZin, the formulation used in the study, was associated with significant decreases in serum C-reactive protein levels below baseline levels (P value of less than .05). CRP levels fell from a range of 4-23 mg/L at baseline to a range of 3.8-16 mg/L after treatment.

LitoZin, which is manufactured by Dansk Droge Ltd., Ishøj, Denmark, and distributed in Europe, is expected to be marketed in 2005 in the United States by EuroPharma Inc., Green Bay, Wis.

Side effects were comparable with placebo, and no patients dropped out of the study, reported Dr. Winther.

Dr. Winther disclosed that he has no financial interest in the product.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

ACR guidelines instruct physicians to start treatment with acetaminophen and then move on to nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors as the second and third lines of treatment, if pain control is not adequate.

Inadequate pain relief with acetaminophen may result from the adherence to the dosing schedule, said Dr. Altman at the meeting, which was sponsored by the Osteoarthritis Research Society International. The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman, of the division of rheumatology and arthritis at the University of California, Los Angeles. “Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it.”

At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0-4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81). “I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use.

The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

ACR guidelines instruct physicians to start treatment with acetaminophen and then move on to nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors as the second and third lines of treatment, if pain control is not adequate.

Inadequate pain relief with acetaminophen may result from the adherence to the dosing schedule, said Dr. Altman at the meeting, which was sponsored by the Osteoarthritis Research Society International. The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman, of the division of rheumatology and arthritis at the University of California, Los Angeles. “Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it.”

At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0-4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81). “I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use.

The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

CHICAGO — A new study confirms that acetaminophen is safe and effective for the treatment of pain associated with osteoarthritis of the knee and hip.

The results reinforce the American College of Rheumatology guidelines that recommend acetaminophen as a first-line therapy to relieve osteoarthritis (OA) pain, but contradict other studies that suggest acetaminophen may not be useful in treating OA pain.

“People were questioning whether acetaminophen had any role, and I think this study clearly shows it does,” lead author Roy D. Altman, M.D., reported in a poster presentation at the 2004 World Congress on Osteoarthritis. “People with mild to moderate pain with osteoarthritis often get adequate pain relief from acetaminophen.”

These findings are particularly relevant in the post-Vioxx environment, which has many patients concerned about the safety of some prescription arthritis medications.

ACR guidelines instruct physicians to start treatment with acetaminophen and then move on to nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors as the second and third lines of treatment, if pain control is not adequate.

Inadequate pain relief with acetaminophen may result from the adherence to the dosing schedule, said Dr. Altman at the meeting, which was sponsored by the Osteoarthritis Research Society International. The maximum recommended dosage is 1 g four times per day.

The study randomized 483 patients—who were at least 40 years old with moderate to moderately severe OA pain—to treatment with acetaminophen extended-release (ER) caplets at daily doses of 1,950 mg, 3,900 mg, or placebo. The long-acting formulation reduced the number of daily doses to just two for those taking the higher dose.

“One of the benefits of this dosing is that people will take it twice a day,” said Dr. Altman, of the division of rheumatology and arthritis at the University of California, Los Angeles. “Part of the problem is that people haven't been taking acetaminophen in doses that were adequate enough to give them pain relief because they start forgetting to take it.”

At 12 weeks, acetaminophen ER 3,900 mg/day was superior to placebo for all three primary efficacy end points: the average change in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score (mean decrease of 25 mm vs. 19 mm), the WOMAC physical function score (mean decrease of 24 mm vs. 18 mm), and the patient's global assessment of therapy on the 0-4 Likert scale (mean change 2.11 vs. 1.81).

In contrast, acetaminophen ER at 1,950 mg/day was superior to placebo only in the patient's global assessment of therapy (mean change 2.09 vs. 1.81). “I think when you get into 2 grams a day, [the dosage] just isn't adequate, and this [study] shows that,” Dr. Altman said.

No serious drug-related adverse events occurred, which was supported by McNeil Consumer & Specialty Pharmaceuticals, the manufacturer of Tylenol.

“There has been an unnecessary battle between NSAIDs and acetaminophen,” Dr. Altman said. “Some areas work better than others. My feeling is that combination therapy has to be looked at more carefully.”

A second study presented at the meeting found that 4,000 mg/day of acetaminophen was safe for up to 12 months of use.

The double-blind study involved 571 patients with mild to moderately severe OA pain of the hip or knee who were randomized to treatment with 4,000 mg/day of acetaminophen or 750 mg/day of naproxen.

The WOMAC scores in pain, stiffness, and physical function among the 290 patients treated with acetaminophen were comparable to those of patients treated with naproxen, without any clinically important adverse effects, reported lead author Anthony Temple, M.D., vice president of medical affairs at McNeil Consumer & Specialty Pharmaceuticals in Fort Washington, Pa.

TORONTO – Pediatricians often prescribe medications for psychiatric disorders with an insufficient knowledge base and little collaborative help from psychiatrists, according to results of a cross-sectional survey of primary care pediatricians presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“Having done this survey, we are very concerned that inadequate psychiatrist-pediatrician communication may lead to mismanagement of children with psychiatric disorders,” commented lead investigator Wendy Ross, M.D., of Children's Hospital Boston and Harvard University, Boston.

Increases in the primary care diagnosis and management of psychiatric disorders in children have created a need for more psychopharmacology knowledge among pediatricians and a demand for accessible collaborative psychiatric care, Dr. Ross said.

Investigators mailed surveys to 200 pediatricians randomly selected from the Massachusetts chapter of the American Academy of Pediatrics and received 100 surveys.

The mean age of respondents was 47 years, 45% were female, and the mean duration of practice was 16 years.

Almost all pediatricians (98%) reported longer than preferred wait times for their patients to see a psychiatrist. Major barriers to psychiatric referral in the study were the availability of psychiatrists (97%) and insurance coverage (97%), she reported.

Only 5% of pediatricians reported feeling adequately trained in psychiatric conditions and treatment, and most believed more training should be included in residency (92%) and continuing medical education (95%).

Still, a majority of the pediatricians reported that they had diagnosed attention-deficit hyperactivity disorder (ADHD) (93%), depression (75%), and anxiety (69%). Pediatricians were more likely to prefer that a psychiatrist prescribe medication for children with anxiety (87%) and depression (85%) than for ADHD (22%).

“For depression and anxiety, fewer, but still many, are diagnosing,” Dr. Ross said. “Almost all of these physicians would prefer that psychiatry manage these patients.”

At the time of the study, 32% reported that they referred more than 21 patients to psychiatry in the past year. Overall, 66% reported more than 21 patients currently under psychiatric care.

Many pediatricians reported initiating medications for ADHD (86%), depression (57%), and anxiety (44%). Pediatricians refilled medications prescribed by a psychiatrist for ADHD (88%), depression (76%), and anxiety (72%).

However, only 14% of pediatricians said they received any information after a psychiatric referral, Dr. Ross said.

More than 90% of respondents reported that they are more likely to get communication from surgeons and other medical subspecialists than from psychiatrists. Slightly more than half of pediatricians (51%) felt confidentiality was not a barrier to communication.

The study was limited by a small sample size and single geographic location, but Dr. Ross added that the demographics of their population are comparable to the national results of the AAP national survey of pediatricians.

The next step is to survey pediatricians and psychiatrists on a larger scale, and to look for possible solutions.

The survey showed that pediatricians themselves could do more to reach out to their colleagues.

Although 66% of pediatricians agreed that prior communication with a psychiatrist might result in more communication after a patient visit, only 25% reported speaking with a psychiatrist first. Indeed, 28% of those who contacted a psychiatrist prior to a patient's visit reported that they were likely to receive follow-up communication.

TORONTO – Pediatricians often prescribe medications for psychiatric disorders with an insufficient knowledge base and little collaborative help from psychiatrists, according to results of a cross-sectional survey of primary care pediatricians presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“Having done this survey, we are very concerned that inadequate psychiatrist-pediatrician communication may lead to mismanagement of children with psychiatric disorders,” commented lead investigator Wendy Ross, M.D., of Children's Hospital Boston and Harvard University, Boston.

Increases in the primary care diagnosis and management of psychiatric disorders in children have created a need for more psychopharmacology knowledge among pediatricians and a demand for accessible collaborative psychiatric care, Dr. Ross said.

Investigators mailed surveys to 200 pediatricians randomly selected from the Massachusetts chapter of the American Academy of Pediatrics and received 100 surveys.

The mean age of respondents was 47 years, 45% were female, and the mean duration of practice was 16 years.

Almost all pediatricians (98%) reported longer than preferred wait times for their patients to see a psychiatrist. Major barriers to psychiatric referral in the study were the availability of psychiatrists (97%) and insurance coverage (97%), she reported.

Only 5% of pediatricians reported feeling adequately trained in psychiatric conditions and treatment, and most believed more training should be included in residency (92%) and continuing medical education (95%).

Still, a majority of the pediatricians reported that they had diagnosed attention-deficit hyperactivity disorder (ADHD) (93%), depression (75%), and anxiety (69%). Pediatricians were more likely to prefer that a psychiatrist prescribe medication for children with anxiety (87%) and depression (85%) than for ADHD (22%).

“For depression and anxiety, fewer, but still many, are diagnosing,” Dr. Ross said. “Almost all of these physicians would prefer that psychiatry manage these patients.”

At the time of the study, 32% reported that they referred more than 21 patients to psychiatry in the past year. Overall, 66% reported more than 21 patients currently under psychiatric care.

Many pediatricians reported initiating medications for ADHD (86%), depression (57%), and anxiety (44%). Pediatricians refilled medications prescribed by a psychiatrist for ADHD (88%), depression (76%), and anxiety (72%).

However, only 14% of pediatricians said they received any information after a psychiatric referral, Dr. Ross said.

More than 90% of respondents reported that they are more likely to get communication from surgeons and other medical subspecialists than from psychiatrists. Slightly more than half of pediatricians (51%) felt confidentiality was not a barrier to communication.

The study was limited by a small sample size and single geographic location, but Dr. Ross added that the demographics of their population are comparable to the national results of the AAP national survey of pediatricians.

The next step is to survey pediatricians and psychiatrists on a larger scale, and to look for possible solutions.

The survey showed that pediatricians themselves could do more to reach out to their colleagues.

Although 66% of pediatricians agreed that prior communication with a psychiatrist might result in more communication after a patient visit, only 25% reported speaking with a psychiatrist first. Indeed, 28% of those who contacted a psychiatrist prior to a patient's visit reported that they were likely to receive follow-up communication.

TORONTO – Pediatricians often prescribe medications for psychiatric disorders with an insufficient knowledge base and little collaborative help from psychiatrists, according to results of a cross-sectional survey of primary care pediatricians presented at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“Having done this survey, we are very concerned that inadequate psychiatrist-pediatrician communication may lead to mismanagement of children with psychiatric disorders,” commented lead investigator Wendy Ross, M.D., of Children's Hospital Boston and Harvard University, Boston.

Increases in the primary care diagnosis and management of psychiatric disorders in children have created a need for more psychopharmacology knowledge among pediatricians and a demand for accessible collaborative psychiatric care, Dr. Ross said.

Investigators mailed surveys to 200 pediatricians randomly selected from the Massachusetts chapter of the American Academy of Pediatrics and received 100 surveys.

The mean age of respondents was 47 years, 45% were female, and the mean duration of practice was 16 years.

Almost all pediatricians (98%) reported longer than preferred wait times for their patients to see a psychiatrist. Major barriers to psychiatric referral in the study were the availability of psychiatrists (97%) and insurance coverage (97%), she reported.

Only 5% of pediatricians reported feeling adequately trained in psychiatric conditions and treatment, and most believed more training should be included in residency (92%) and continuing medical education (95%).

Still, a majority of the pediatricians reported that they had diagnosed attention-deficit hyperactivity disorder (ADHD) (93%), depression (75%), and anxiety (69%). Pediatricians were more likely to prefer that a psychiatrist prescribe medication for children with anxiety (87%) and depression (85%) than for ADHD (22%).

“For depression and anxiety, fewer, but still many, are diagnosing,” Dr. Ross said. “Almost all of these physicians would prefer that psychiatry manage these patients.”

At the time of the study, 32% reported that they referred more than 21 patients to psychiatry in the past year. Overall, 66% reported more than 21 patients currently under psychiatric care.

Many pediatricians reported initiating medications for ADHD (86%), depression (57%), and anxiety (44%). Pediatricians refilled medications prescribed by a psychiatrist for ADHD (88%), depression (76%), and anxiety (72%).

However, only 14% of pediatricians said they received any information after a psychiatric referral, Dr. Ross said.

More than 90% of respondents reported that they are more likely to get communication from surgeons and other medical subspecialists than from psychiatrists. Slightly more than half of pediatricians (51%) felt confidentiality was not a barrier to communication.

The study was limited by a small sample size and single geographic location, but Dr. Ross added that the demographics of their population are comparable to the national results of the AAP national survey of pediatricians.

The next step is to survey pediatricians and psychiatrists on a larger scale, and to look for possible solutions.

The survey showed that pediatricians themselves could do more to reach out to their colleagues.

Although 66% of pediatricians agreed that prior communication with a psychiatrist might result in more communication after a patient visit, only 25% reported speaking with a psychiatrist first. Indeed, 28% of those who contacted a psychiatrist prior to a patient's visit reported that they were likely to receive follow-up communication.