Robert Finn

SAN ANTONIO — Vardenafil improved premature ejaculation more than sertraline, Frank Sommer, M.D., reported at the annual meeting of the American Urological Association.

Both vardenafil (Levitra), a phosphodiesterase-5 inhibitor, and sertraline (Zoloft), a selective serotonin reuptake inhibitor, resulted in significant improvements in several measures of premature ejaculation (PE) over baseline, but vardenafil proved significantly better than sertraline on all measures.

The relatively small, crossover study involved 34 heterosexual men who reported PE more than half the time and who had intravaginal ejaculatory latency times (IVELT) of less than 1.5 minutes at baseline.

PE was the primary complaint in 8 (24%) of the men and was secondary (in most cases to erectile dysfunction) in the remaining 26 men (77%).

After a 4-week run-in period, 17 men were given 10-mg vardenafil 10 minutes before intercourse for 6 weeks. The other 17 received 50 mg of sertraline 4 hours before intercourse.

After a 1-week washout period, the men who had been receiving sertraline switched to vardenafil and vice versa for an additional 6 weeks.

On a self-rating scale of 0–8, where 0 means PE almost never, 4 means PE about half the time, and 8 means PE almost always, the mean score was 6.14 at baseline, 4.28 with sertraline, and 3.2 with vardenafil.

IVELT, as measured by a stopwatch, averaged 0.54 minutes at baseline, 2.87 minutes with sertraline, and 5.23 minutes with vardenafil, reported Dr. Sommer, who conducted the research at the Cologne (Germany) University Medical Center but is now at the University of Hamburg.

Self-ratings of sexual satisfaction, on a 0–5 scale, where 0 means not at all satisfied and 5 means extremely satisfied, averaged 1.4 at baseline, 3.2 with sertraline, and 4.2 with vardenafil. In addition, the partners' sexual satisfaction showed significant increases for sertraline and even more so for vardenafil.

Dr. Sommer stated that he had no conflicts of interest related to his study.

SAN ANTONIO — Vardenafil improved premature ejaculation more than sertraline, Frank Sommer, M.D., reported at the annual meeting of the American Urological Association.

Both vardenafil (Levitra), a phosphodiesterase-5 inhibitor, and sertraline (Zoloft), a selective serotonin reuptake inhibitor, resulted in significant improvements in several measures of premature ejaculation (PE) over baseline, but vardenafil proved significantly better than sertraline on all measures.

The relatively small, crossover study involved 34 heterosexual men who reported PE more than half the time and who had intravaginal ejaculatory latency times (IVELT) of less than 1.5 minutes at baseline.

PE was the primary complaint in 8 (24%) of the men and was secondary (in most cases to erectile dysfunction) in the remaining 26 men (77%).

After a 4-week run-in period, 17 men were given 10-mg vardenafil 10 minutes before intercourse for 6 weeks. The other 17 received 50 mg of sertraline 4 hours before intercourse.

After a 1-week washout period, the men who had been receiving sertraline switched to vardenafil and vice versa for an additional 6 weeks.

On a self-rating scale of 0–8, where 0 means PE almost never, 4 means PE about half the time, and 8 means PE almost always, the mean score was 6.14 at baseline, 4.28 with sertraline, and 3.2 with vardenafil.

IVELT, as measured by a stopwatch, averaged 0.54 minutes at baseline, 2.87 minutes with sertraline, and 5.23 minutes with vardenafil, reported Dr. Sommer, who conducted the research at the Cologne (Germany) University Medical Center but is now at the University of Hamburg.

Self-ratings of sexual satisfaction, on a 0–5 scale, where 0 means not at all satisfied and 5 means extremely satisfied, averaged 1.4 at baseline, 3.2 with sertraline, and 4.2 with vardenafil. In addition, the partners' sexual satisfaction showed significant increases for sertraline and even more so for vardenafil.

Dr. Sommer stated that he had no conflicts of interest related to his study.

SAN ANTONIO — Vardenafil improved premature ejaculation more than sertraline, Frank Sommer, M.D., reported at the annual meeting of the American Urological Association.

Both vardenafil (Levitra), a phosphodiesterase-5 inhibitor, and sertraline (Zoloft), a selective serotonin reuptake inhibitor, resulted in significant improvements in several measures of premature ejaculation (PE) over baseline, but vardenafil proved significantly better than sertraline on all measures.

The relatively small, crossover study involved 34 heterosexual men who reported PE more than half the time and who had intravaginal ejaculatory latency times (IVELT) of less than 1.5 minutes at baseline.

PE was the primary complaint in 8 (24%) of the men and was secondary (in most cases to erectile dysfunction) in the remaining 26 men (77%).

After a 4-week run-in period, 17 men were given 10-mg vardenafil 10 minutes before intercourse for 6 weeks. The other 17 received 50 mg of sertraline 4 hours before intercourse.

After a 1-week washout period, the men who had been receiving sertraline switched to vardenafil and vice versa for an additional 6 weeks.

On a self-rating scale of 0–8, where 0 means PE almost never, 4 means PE about half the time, and 8 means PE almost always, the mean score was 6.14 at baseline, 4.28 with sertraline, and 3.2 with vardenafil.

IVELT, as measured by a stopwatch, averaged 0.54 minutes at baseline, 2.87 minutes with sertraline, and 5.23 minutes with vardenafil, reported Dr. Sommer, who conducted the research at the Cologne (Germany) University Medical Center but is now at the University of Hamburg.

Self-ratings of sexual satisfaction, on a 0–5 scale, where 0 means not at all satisfied and 5 means extremely satisfied, averaged 1.4 at baseline, 3.2 with sertraline, and 4.2 with vardenafil. In addition, the partners' sexual satisfaction showed significant increases for sertraline and even more so for vardenafil.

Dr. Sommer stated that he had no conflicts of interest related to his study.

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek, of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, she noted.

Dr. Roczek and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek, of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, she noted.

Dr. Roczek and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — A less-than-perfect score on a five-item, 10-point cardiovascular profile predicts a poorer outcome for a fetus with heart failure, according to a poster presented by Aleksandra Roczek, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine.

Fetuses in this high-risk group warrant closer follow-up and management from both the obstetric and prenatal cardiology point of view, concluded Dr. Roczek, of the University of South Florida, Tampa.

Poor scores on three of the five items—cardiomegaly, hydrops, and venous Doppler measurements—were especially predictive of mortality, she noted.

Dr. Roczek and her colleagues conducted a retrospective examination of 92 pregnancies where fetuses were judged to be at risk for heart failure on the basis of echocardiography and Doppler velocimetry. Of those fetuses, 53 (57%) survived and 39 (43%) did not.

The cardiovascular profile score awards two points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size. The score in each domain is decreased by two points for severe signs and by one point for intermediate signs.

Fetuses with abnormal venous Doppler had a mortality rate of 64%. Mortality was 62.5% in fetuses with hydrops, and 60% in fetuses with cardiomegaly.

The other two factors were less predictive of mortality. Fetuses with abnormal heart function had a 33% mortality, and those with abnormal arterial Doppler had a 17% mortality.

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and six (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two of hypoplastic left heart syndrome, two of ventricular septal defect, two of left atrial isomerism, two of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

However, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and six (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two of hypoplastic left heart syndrome, two of ventricular septal defect, two of left atrial isomerism, two of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

However, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

RENO, NEV. — Fetal echocardiography before 16 weeks of gestation is feasible and can detect a substantial proportion of cardiac lesions, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

The technique does have limitations regarding accurate visualization of the great artery relationship and the crux of the heart. It may therefore be best to reserve early echocardiography for cases at the greatest risk for cardiac defects. Second-trimester echocardiograms remain the gold standard, concluded Fionnuala McAuliffe, M.D., of University College Dublin (Ireland) and colleagues.

The study involved 160 fetal echocardiograms performed before the 16th week, with an average gestation time of 13.5 weeks. Investigators used the transabdominal approach for 100 cases, and the transvaginal approach in 60 cases in which the transabdominal approach yielded poor visualization.

Of the 160 patients, 100 were referred because of nuchal translucency greater than the 95th percentile, 51 because of a family history of congenital cardiac defects, and 9 because of the presence of extracardiac lesions.

Adequate cardiac examinations were possible in 152 cases, and pregnancy outcome was available in 137 cases. Of those, there were 20 cardiac defects. Fourteen (70%) showed an abnormality on the early echocardiogram, and six (30%) were passed as normal.

The early echocardiogram identified two cases of ectopia cordis, two cases of atrioventricular septal defect, two of hypoplastic left heart syndrome, two of ventricular septal defect, two of left atrial isomerism, two of hypoplastic right ventricle, and one case each of double outlet right ventricle and cardiac diverticulum.

However, the early echocardiogram failed to detect three cases of ventricular septal defect, two cases of dextro-looped transposition of the great arteries, and one case of hypertrophic cardiomyopathy.

A four-chamber view of the heart was obtained in all of the cases. The atrioventricular valves could be visualized 96% of the time, the aorta and pulmonary artery 95% of the time, and the inferior and superior vena cava 76% of the time.

Early fetal echocardiography was less effective in visualizing the aortic and ductal arches (45% of the time), branch pulmonary arteries (37% of the time), and pulmonary veins (19% of the time).

SAN FRANCISCO — Some diagnostic tests for suspected Helicobacter pylori infection are better validated in adults than in children, John D. Snyder, M.D., reported at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Furthermore, most of the diagnostic tests for H. pylori don't distinguish asymptomatic infection from disease. About 80% of people infected with H. pylori have no measurable disease, said Dr. Snyder of UCSF. He discussed the following tests and their applicability to children.

▸ Esophagogastroduodenoscopy. EGD combined with silver-stained biopsies remains the standard for diagnosis. It's the only test that can distinguish asymptomatic infection from disease, and it works as well in children as in adults. But EGD is invasive and relatively expensive.

▸ Commercial serology tests. These tests have about 90% sensitivity and specificity in adults, but they perform significantly worse in children. Published studies of sensitivity and specificity in children have yielded estimates of 63%–78% sensitivity and 84%–88% specificity.

The reasons for this poor performance could be that children have lower antibody titers than adults, antibodies can persist long after an infection is eradicated, maternal antibodies can be transmitted to infants, and immunosuppressant proteins differ in children and adults.

▸ Urea breath test. This test shows some promise. It uses

In adults, sensitivity and specificity have been above 95%. Only limited data are available for children, but those data are encouraging. There's a need for evaluation in larger cohorts of children, especially those under age 3 years.

▸ Stool antigen test. This test is an enzyme-linked immunoadsorbent assay for bacterial protein. It has high sensitivity and specificity in adults and can detect eradication as soon as 2 weeks after therapy. The FDA has approved the stool antigen test as a test of cure in adults.

There have only been two small, single-center trials of this test in children, however.

Dr. Snyder recommended focusing on the history and physical exam in children presenting with abdominal pain. Consider common causes, such as constipation, Giardia, urinary tract infections, and lactose intolerance. Conduct therapeutic trials of a high-fiber diet, a lactose-free diet, or acid suppression.

If none of these therapies resolves the symptoms, consider EGD with biopsy.

First-line treatment recommendations for H. pylori infection are amoxicillin, 50 mg/kg per day in two doses, up to 2 g per day; clarithromycin, 15 mg/kg per day in two doses up to 1 g per day; or a proton pump inhibitor (PPI), 1 mg/kg per day up to 20 mg b.i.d. for 14 days.

The second-line treatment recommendation is amoxicillin plus metronidazole (20 mg/kg per day) plus a PPI for 7–14 days.

And the third-line treatment is clarithromycin plus metronidazole plus a PPI for 7–14 days.

SAN FRANCISCO — Some diagnostic tests for suspected Helicobacter pylori infection are better validated in adults than in children, John D. Snyder, M.D., reported at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Furthermore, most of the diagnostic tests for H. pylori don't distinguish asymptomatic infection from disease. About 80% of people infected with H. pylori have no measurable disease, said Dr. Snyder of UCSF. He discussed the following tests and their applicability to children.

▸ Esophagogastroduodenoscopy. EGD combined with silver-stained biopsies remains the standard for diagnosis. It's the only test that can distinguish asymptomatic infection from disease, and it works as well in children as in adults. But EGD is invasive and relatively expensive.

▸ Commercial serology tests. These tests have about 90% sensitivity and specificity in adults, but they perform significantly worse in children. Published studies of sensitivity and specificity in children have yielded estimates of 63%–78% sensitivity and 84%–88% specificity.

The reasons for this poor performance could be that children have lower antibody titers than adults, antibodies can persist long after an infection is eradicated, maternal antibodies can be transmitted to infants, and immunosuppressant proteins differ in children and adults.

▸ Urea breath test. This test shows some promise. It uses

In adults, sensitivity and specificity have been above 95%. Only limited data are available for children, but those data are encouraging. There's a need for evaluation in larger cohorts of children, especially those under age 3 years.

▸ Stool antigen test. This test is an enzyme-linked immunoadsorbent assay for bacterial protein. It has high sensitivity and specificity in adults and can detect eradication as soon as 2 weeks after therapy. The FDA has approved the stool antigen test as a test of cure in adults.

There have only been two small, single-center trials of this test in children, however.

Dr. Snyder recommended focusing on the history and physical exam in children presenting with abdominal pain. Consider common causes, such as constipation, Giardia, urinary tract infections, and lactose intolerance. Conduct therapeutic trials of a high-fiber diet, a lactose-free diet, or acid suppression.

If none of these therapies resolves the symptoms, consider EGD with biopsy.

First-line treatment recommendations for H. pylori infection are amoxicillin, 50 mg/kg per day in two doses, up to 2 g per day; clarithromycin, 15 mg/kg per day in two doses up to 1 g per day; or a proton pump inhibitor (PPI), 1 mg/kg per day up to 20 mg b.i.d. for 14 days.

The second-line treatment recommendation is amoxicillin plus metronidazole (20 mg/kg per day) plus a PPI for 7–14 days.

And the third-line treatment is clarithromycin plus metronidazole plus a PPI for 7–14 days.

SAN FRANCISCO — Some diagnostic tests for suspected Helicobacter pylori infection are better validated in adults than in children, John D. Snyder, M.D., reported at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Furthermore, most of the diagnostic tests for H. pylori don't distinguish asymptomatic infection from disease. About 80% of people infected with H. pylori have no measurable disease, said Dr. Snyder of UCSF. He discussed the following tests and their applicability to children.

▸ Esophagogastroduodenoscopy. EGD combined with silver-stained biopsies remains the standard for diagnosis. It's the only test that can distinguish asymptomatic infection from disease, and it works as well in children as in adults. But EGD is invasive and relatively expensive.

▸ Commercial serology tests. These tests have about 90% sensitivity and specificity in adults, but they perform significantly worse in children. Published studies of sensitivity and specificity in children have yielded estimates of 63%–78% sensitivity and 84%–88% specificity.

The reasons for this poor performance could be that children have lower antibody titers than adults, antibodies can persist long after an infection is eradicated, maternal antibodies can be transmitted to infants, and immunosuppressant proteins differ in children and adults.

▸ Urea breath test. This test shows some promise. It uses

In adults, sensitivity and specificity have been above 95%. Only limited data are available for children, but those data are encouraging. There's a need for evaluation in larger cohorts of children, especially those under age 3 years.

▸ Stool antigen test. This test is an enzyme-linked immunoadsorbent assay for bacterial protein. It has high sensitivity and specificity in adults and can detect eradication as soon as 2 weeks after therapy. The FDA has approved the stool antigen test as a test of cure in adults.

There have only been two small, single-center trials of this test in children, however.

Dr. Snyder recommended focusing on the history and physical exam in children presenting with abdominal pain. Consider common causes, such as constipation, Giardia, urinary tract infections, and lactose intolerance. Conduct therapeutic trials of a high-fiber diet, a lactose-free diet, or acid suppression.

If none of these therapies resolves the symptoms, consider EGD with biopsy.

First-line treatment recommendations for H. pylori infection are amoxicillin, 50 mg/kg per day in two doses, up to 2 g per day; clarithromycin, 15 mg/kg per day in two doses up to 1 g per day; or a proton pump inhibitor (PPI), 1 mg/kg per day up to 20 mg b.i.d. for 14 days.

The second-line treatment recommendation is amoxicillin plus metronidazole (20 mg/kg per day) plus a PPI for 7–14 days.

And the third-line treatment is clarithromycin plus metronidazole plus a PPI for 7–14 days.

SAN FRANCISCO — In the wake of the Women's Health Initiative, “it's easier to get OxyContin out of a doctor's office than Prempro,” Melissa A. McNeil, M.D., joked at the annual meeting of the American College of Physicians.

But how then is a physician to manage the vasomotor symptoms of menopause? Dr. McNeil of the University of Pittsburgh said that, although many remedies have advocates, few have been evaluated in controlled studies. She offered several evidence-based suggestions:

▸ Time. Tincture of time works for many women. Although 75% of menopausal women are troubled by hot flashes, for 30%–50% the symptoms improve within months, and hot flashes resolve for most women within 4–5 years.

The fact that hot flashes frequently resolve spontaneously leads to a large placebo effect—in the neighborhood of 25%—in studies of drugs and supplements.

▸ Progestins. There's good evidence from randomized, controlled trials for the efficacy of a number of progestins. Medroxyprogesterone and megestrol (Megace) both were reported to result in a 74% reduction in hot flashes. Depo-Provera was reported in one study to result in a 90% reduction in hot flashes. Uterine bleeding is a frequent side effect of progestin therapy, limiting its use in women with uterine cysts. Furthermore, there are no long-term safety data available.

The most significant bar to progestin therapy, however, comes from Women's Health Initiative results, which suggest that progesterone supplementation may confer an increased risk of certain cancers or adverse cardiovascular events, compared with estrogen alone.

▸ Clonidine and methyldopa. Studies of antihypertensive agents such as clonidine and methyldopa suggest a relatively small effect on hot flashes. Use of clonidine, in particular, is limited by side effects, including dry mouth, constipation, and drowsiness. Still, these drugs may be useful in women who need blood pressure treatment in addition to hot-flash relief.

▸ Nonhormonal therapies. Antidepressants, which are the most promising nonhormonal therapies for hot flashes, have become the mainstay of treatment.

Venlafaxine, fluoxetine, and paroxetine all appear to result in 50%–65% reductions in hot flashes in controlled trials, although some of those trials studied breast cancer survivors, who may not be representative of the entire population of menopausal women.

One advantage of antidepressants is that their effect on hot flashes seems to begin relatively quickly—in about 1–2 weeks—compared with about a month for their effects on depression.

▸ Gabapentin. This drug appears to have a modest effect on hot flashes, with a reduction of about 50% in one small trial. About half the women in that trial experienced at least one adverse event, including dizziness, somnolence, palpitations, or peripheral edema.

▸ Nutritional supplements. Although these supplements have received a lot of coverage in the lay press, scientific evidence of their efficacy in treating hot flashes is lacking. Soy phytoestrogens engendered a great deal of enthusiasm a few years back, and several small studies seemed to indicate effectiveness, but more recently a larger controlled trial found no effect on hot flashes. Mixed evidence of effectiveness has been found for vitamin E and black cohosh, but most studies have been small and unblinded. Evening primrose oil, ginseng, and wild yam cream have all been shown to be ineffective.

In selecting a treatment for a patient's hot flashes, Dr. McNeil said that she always looks for a twofer. “If I'm treating depression, I'll go for an antidepressant,” she said. “If they have chronic pain I think about gabapentin. And if they have hypertension I might use clonidine. If they're straight out of the starting block, I'd think about venlafaxine as my starting point.”

Dr. McNeil said she had no conflicts of interest related to her presentation.

SAN FRANCISCO — In the wake of the Women's Health Initiative, “it's easier to get OxyContin out of a doctor's office than Prempro,” Melissa A. McNeil, M.D., joked at the annual meeting of the American College of Physicians.

But how then is a physician to manage the vasomotor symptoms of menopause? Dr. McNeil of the University of Pittsburgh said that, although many remedies have advocates, few have been evaluated in controlled studies. She offered several evidence-based suggestions:

▸ Time. Tincture of time works for many women. Although 75% of menopausal women are troubled by hot flashes, for 30%–50% the symptoms improve within months, and hot flashes resolve for most women within 4–5 years.

The fact that hot flashes frequently resolve spontaneously leads to a large placebo effect—in the neighborhood of 25%—in studies of drugs and supplements.

▸ Progestins. There's good evidence from randomized, controlled trials for the efficacy of a number of progestins. Medroxyprogesterone and megestrol (Megace) both were reported to result in a 74% reduction in hot flashes. Depo-Provera was reported in one study to result in a 90% reduction in hot flashes. Uterine bleeding is a frequent side effect of progestin therapy, limiting its use in women with uterine cysts. Furthermore, there are no long-term safety data available.

The most significant bar to progestin therapy, however, comes from Women's Health Initiative results, which suggest that progesterone supplementation may confer an increased risk of certain cancers or adverse cardiovascular events, compared with estrogen alone.

▸ Clonidine and methyldopa. Studies of antihypertensive agents such as clonidine and methyldopa suggest a relatively small effect on hot flashes. Use of clonidine, in particular, is limited by side effects, including dry mouth, constipation, and drowsiness. Still, these drugs may be useful in women who need blood pressure treatment in addition to hot-flash relief.

▸ Nonhormonal therapies. Antidepressants, which are the most promising nonhormonal therapies for hot flashes, have become the mainstay of treatment.

Venlafaxine, fluoxetine, and paroxetine all appear to result in 50%–65% reductions in hot flashes in controlled trials, although some of those trials studied breast cancer survivors, who may not be representative of the entire population of menopausal women.

One advantage of antidepressants is that their effect on hot flashes seems to begin relatively quickly—in about 1–2 weeks—compared with about a month for their effects on depression.

▸ Gabapentin. This drug appears to have a modest effect on hot flashes, with a reduction of about 50% in one small trial. About half the women in that trial experienced at least one adverse event, including dizziness, somnolence, palpitations, or peripheral edema.

▸ Nutritional supplements. Although these supplements have received a lot of coverage in the lay press, scientific evidence of their efficacy in treating hot flashes is lacking. Soy phytoestrogens engendered a great deal of enthusiasm a few years back, and several small studies seemed to indicate effectiveness, but more recently a larger controlled trial found no effect on hot flashes. Mixed evidence of effectiveness has been found for vitamin E and black cohosh, but most studies have been small and unblinded. Evening primrose oil, ginseng, and wild yam cream have all been shown to be ineffective.

In selecting a treatment for a patient's hot flashes, Dr. McNeil said that she always looks for a twofer. “If I'm treating depression, I'll go for an antidepressant,” she said. “If they have chronic pain I think about gabapentin. And if they have hypertension I might use clonidine. If they're straight out of the starting block, I'd think about venlafaxine as my starting point.”

Dr. McNeil said she had no conflicts of interest related to her presentation.

SAN FRANCISCO — In the wake of the Women's Health Initiative, “it's easier to get OxyContin out of a doctor's office than Prempro,” Melissa A. McNeil, M.D., joked at the annual meeting of the American College of Physicians.

But how then is a physician to manage the vasomotor symptoms of menopause? Dr. McNeil of the University of Pittsburgh said that, although many remedies have advocates, few have been evaluated in controlled studies. She offered several evidence-based suggestions:

▸ Time. Tincture of time works for many women. Although 75% of menopausal women are troubled by hot flashes, for 30%–50% the symptoms improve within months, and hot flashes resolve for most women within 4–5 years.

The fact that hot flashes frequently resolve spontaneously leads to a large placebo effect—in the neighborhood of 25%—in studies of drugs and supplements.

▸ Progestins. There's good evidence from randomized, controlled trials for the efficacy of a number of progestins. Medroxyprogesterone and megestrol (Megace) both were reported to result in a 74% reduction in hot flashes. Depo-Provera was reported in one study to result in a 90% reduction in hot flashes. Uterine bleeding is a frequent side effect of progestin therapy, limiting its use in women with uterine cysts. Furthermore, there are no long-term safety data available.

The most significant bar to progestin therapy, however, comes from Women's Health Initiative results, which suggest that progesterone supplementation may confer an increased risk of certain cancers or adverse cardiovascular events, compared with estrogen alone.

▸ Clonidine and methyldopa. Studies of antihypertensive agents such as clonidine and methyldopa suggest a relatively small effect on hot flashes. Use of clonidine, in particular, is limited by side effects, including dry mouth, constipation, and drowsiness. Still, these drugs may be useful in women who need blood pressure treatment in addition to hot-flash relief.

▸ Nonhormonal therapies. Antidepressants, which are the most promising nonhormonal therapies for hot flashes, have become the mainstay of treatment.

Venlafaxine, fluoxetine, and paroxetine all appear to result in 50%–65% reductions in hot flashes in controlled trials, although some of those trials studied breast cancer survivors, who may not be representative of the entire population of menopausal women.

One advantage of antidepressants is that their effect on hot flashes seems to begin relatively quickly—in about 1–2 weeks—compared with about a month for their effects on depression.

▸ Gabapentin. This drug appears to have a modest effect on hot flashes, with a reduction of about 50% in one small trial. About half the women in that trial experienced at least one adverse event, including dizziness, somnolence, palpitations, or peripheral edema.

▸ Nutritional supplements. Although these supplements have received a lot of coverage in the lay press, scientific evidence of their efficacy in treating hot flashes is lacking. Soy phytoestrogens engendered a great deal of enthusiasm a few years back, and several small studies seemed to indicate effectiveness, but more recently a larger controlled trial found no effect on hot flashes. Mixed evidence of effectiveness has been found for vitamin E and black cohosh, but most studies have been small and unblinded. Evening primrose oil, ginseng, and wild yam cream have all been shown to be ineffective.

In selecting a treatment for a patient's hot flashes, Dr. McNeil said that she always looks for a twofer. “If I'm treating depression, I'll go for an antidepressant,” she said. “If they have chronic pain I think about gabapentin. And if they have hypertension I might use clonidine. If they're straight out of the starting block, I'd think about venlafaxine as my starting point.”

Dr. McNeil said she had no conflicts of interest related to her presentation.

PORTLAND, ORE. – Polysomnography may be the gold standard in the diagnosis of obstructive sleep apnea, but in children it should be reserved for high-risk patients, Mark A. Richardson, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In children aged older than 3 years with no underlying condition, a history and a physical exam with findings of adenoid or tonsillar hypertrophy often provide the basis for recommending surgery, said Dr. Richardson of Oregon Health and Science University in Portland. This is especially true if the parents can provide supporting objective information about the child's snoring, such as a videotape or an audiotape.

“I think if you have an otherwise healthy patient with a consistent and chronic history of obstruction at night, that's probably all you really need to have,” Dr. Richardson said.

Polysomnography has several disadvantages. It's expensive, it's unavailable in some areas, and the experience of being in a sleep lab overnight may affect the child's normal sleep. Polysomnography is also subject to false positives and false negatives, especially when an abbreviated “nap” study is used.

Furthermore, polysomnographic results do not correlate well with the behavioral disturbances that about 40% of children with sleep disorders exhibit. Simple snoring and a positive pediatric sleep questionnaire, on the other hand, do correlate with those behavioral disturbances, which include attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and primary disorder of vigilance.

“To me, that suggests that somehow we are missing something on the polysomnography,” Dr. Richardson said. “I don't know what that is, and we're trying to add a variety of measures to polysomnograms right now to see if we can identify that. Obviously, it must be fairly subtle in terms of arousals or partial arousals.”

While clinical judgment is enough for a diagnosis of obstructive sleep apnea in many children, others will require more consideration of polysomnography, Dr. Richardson said. These include children aged under 3 years, those with neuromuscular or craniofacial disorders, and those with complicating medical conditions.

When there is clear evidence of enlarged tonsils or adenoids, adenotonsillectomy is the treatment of choice in children. About 80% will be helped by this surgery, Dr. Richardson said. This is in contrast to adults with obstructive sleep apnea, few of whom respond to adenotonsillectomy.

PORTLAND, ORE. – Polysomnography may be the gold standard in the diagnosis of obstructive sleep apnea, but in children it should be reserved for high-risk patients, Mark A. Richardson, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In children aged older than 3 years with no underlying condition, a history and a physical exam with findings of adenoid or tonsillar hypertrophy often provide the basis for recommending surgery, said Dr. Richardson of Oregon Health and Science University in Portland. This is especially true if the parents can provide supporting objective information about the child's snoring, such as a videotape or an audiotape.

“I think if you have an otherwise healthy patient with a consistent and chronic history of obstruction at night, that's probably all you really need to have,” Dr. Richardson said.

Polysomnography has several disadvantages. It's expensive, it's unavailable in some areas, and the experience of being in a sleep lab overnight may affect the child's normal sleep. Polysomnography is also subject to false positives and false negatives, especially when an abbreviated “nap” study is used.

Furthermore, polysomnographic results do not correlate well with the behavioral disturbances that about 40% of children with sleep disorders exhibit. Simple snoring and a positive pediatric sleep questionnaire, on the other hand, do correlate with those behavioral disturbances, which include attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and primary disorder of vigilance.

“To me, that suggests that somehow we are missing something on the polysomnography,” Dr. Richardson said. “I don't know what that is, and we're trying to add a variety of measures to polysomnograms right now to see if we can identify that. Obviously, it must be fairly subtle in terms of arousals or partial arousals.”

While clinical judgment is enough for a diagnosis of obstructive sleep apnea in many children, others will require more consideration of polysomnography, Dr. Richardson said. These include children aged under 3 years, those with neuromuscular or craniofacial disorders, and those with complicating medical conditions.

When there is clear evidence of enlarged tonsils or adenoids, adenotonsillectomy is the treatment of choice in children. About 80% will be helped by this surgery, Dr. Richardson said. This is in contrast to adults with obstructive sleep apnea, few of whom respond to adenotonsillectomy.

PORTLAND, ORE. – Polysomnography may be the gold standard in the diagnosis of obstructive sleep apnea, but in children it should be reserved for high-risk patients, Mark A. Richardson, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

In children aged older than 3 years with no underlying condition, a history and a physical exam with findings of adenoid or tonsillar hypertrophy often provide the basis for recommending surgery, said Dr. Richardson of Oregon Health and Science University in Portland. This is especially true if the parents can provide supporting objective information about the child's snoring, such as a videotape or an audiotape.

“I think if you have an otherwise healthy patient with a consistent and chronic history of obstruction at night, that's probably all you really need to have,” Dr. Richardson said.

Polysomnography has several disadvantages. It's expensive, it's unavailable in some areas, and the experience of being in a sleep lab overnight may affect the child's normal sleep. Polysomnography is also subject to false positives and false negatives, especially when an abbreviated “nap” study is used.

Furthermore, polysomnographic results do not correlate well with the behavioral disturbances that about 40% of children with sleep disorders exhibit. Simple snoring and a positive pediatric sleep questionnaire, on the other hand, do correlate with those behavioral disturbances, which include attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and primary disorder of vigilance.

“To me, that suggests that somehow we are missing something on the polysomnography,” Dr. Richardson said. “I don't know what that is, and we're trying to add a variety of measures to polysomnograms right now to see if we can identify that. Obviously, it must be fairly subtle in terms of arousals or partial arousals.”

While clinical judgment is enough for a diagnosis of obstructive sleep apnea in many children, others will require more consideration of polysomnography, Dr. Richardson said. These include children aged under 3 years, those with neuromuscular or craniofacial disorders, and those with complicating medical conditions.

When there is clear evidence of enlarged tonsils or adenoids, adenotonsillectomy is the treatment of choice in children. About 80% will be helped by this surgery, Dr. Richardson said. This is in contrast to adults with obstructive sleep apnea, few of whom respond to adenotonsillectomy.

PORTLAND, ORE. – Despite common perceptions among medical professionals and the general public, anorexia nervosa is not a psychosocial disease, Julie K. O'Toole, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Rather, it is a brain disorder and should be seen as such, said Dr. O'Toole, medical director of the Kartini Clinic for Disordered Eating, Portland, Ore. She discussed several of the fallacies surrounding anorexia nervosa:

▸ Anorexia nervosa is caused by over-enmeshed mothers. Dr. O'Toole said she has seen no evidence of any single pattern of mothering in her patients. While it may be true that mothers draw closer to their children with anorexia, this is probably a consequence rather than a cause of the disease. Throughout the animal kingdom, mothers draw closer to offspring who are ill or otherwise in danger.

▸ Children choose anorexia to look like models, because of the extreme examples of thinness in the press. The Kartini Clinic treats children who were home-schooled on farms with no television and no access to fashion magazines. Their anorexia is identical to that of other children.

“This is not a volitional disease, andwe find [this explanation] extremely trivializing of a severe brain disorder,” Dr. O'Toole said.

Nevertheless, the dominant images of thinness in the media do make it much harder to get children into remission. Dr. O'Toole likened it to swimming upstream against the prevailing images of what women should look like. But these images are not causal.

▸ Anorexia nervosa is a condition of spoiled, upper-class kids. Several formal epidemiologic studies have failed to find any link between anorexia and social class. At the Kartini Clinic, workers engage in an informal “map epidemiology,” placing a flag corresponding to the homes of their patients in a map of the three counties of Portland. What's striking is the evenness of the distribution, with no concentration of flags in wealthier neighborhoods.

▸ Anorexia nervosa is a condition of white and Western societies. The disease has certainly been seen in non-Westernized Arabic girls, as well as Asians.

“We rarely see African American children in our Oregon practice.

“Yet even if this were the universal experience, and anorexia nervosa were a disease of Westernized whites only, that wouldn't make it a psychosocial disease,” said Dr. O'Toole.

You won't see many whites in a clinic for sickle-cell disease, but that doesn't make that disorder psychosocial in nature, she said.

Likewise, acute lymphocytic leukemia is more common among white children who have middle-class or upper-middle-class backgrounds, but that doesn't make it a psychosocial illness.

▸ Anorexia is all about control. This is the dominant paradigm these days, and even patients will attribute their disease to a need to control one thing in their lives. Dr. O'Toole regards this as too facile an explanation that implies a level of volition that patients only wish that they had.

Moreover, it's dangerous to trust a patient's own explanations of the etiology of her disease, she said. In the 16th century, people with leprosy were likely to attribute their disease to some offense they committed against God, but that didn't make it true.

“I've always been puzzled about why parents cling to the notion that they did something wrong,” Dr. O'Toole commented.

“We tell them, 'You didn't cause this. You couldn't cause this.' We would rather blame ourselves than believe that horrible things could happen to our children, and we are powerless to affect it.”

The Kartini Clinic's opening message is, “We treat children and adolescents in the belief that parents do not cause and children do not choose to have eating disorders.”

Rethinking the purely psychoanalytic model has a number of implications. For one thing, parents can quit blaming themselves, family dysfunction, or careless comments for causing their children's anorexia.

In addition, everyone can stop treating the patient as if it were a volitional disease, and useless “arguing with the disease” can cease. As a brain disorder, anorexia nervosa is not amenable to rational thought.

Furthermore, family and physicians can focus on creating a safe medical environment in which the child can achieve remission and minimize the sequelae of the disease.

Finally, rejecting the purely psychoanalytic paradigm allows the patient to receive the same compassion and understanding as do victims of other medical diseases.

A child with anorexia nervosa should be hospitalized when presenting with certain signs and symptoms. (See box.)

Of course, weight restoration is key, she added.

Selective serotonin reuptake inhibitors are not useful for anorexia nervosa as such but do treat concomitant anxiety, panic, depression, and obsessive-compulsive disorder.

The antipsychotics olanzapine (Zyprexa, 2.5 mg) and risperidone (Risperdal, 0.5 mg) are useful but have side effects including sedation, hyperprolactinemia, type 2 diabetes, and extrapyramidal symptoms. Dr. O'Toole prefers starting with a low dose (25 mg) of Seroquel (quetiapine) at bedtime.

Indications for Hospitalization

▸ Weight less than 75% of the minimum weight for health.

▸ Heart rate less than 45 beats per minute (bpm).

▸ QTc interval greater than 0.444 ms.

▸ Temperature less than 97.3° F (36.3° C).

▸ Decrease in systolic blood pressure from lying to standing of 10 mm Hg or more.

▸ Increase in heart rate from lying to standing after 2.4 minutes of 35 bpm or more.

▸ Potassium level less than 3.0 mEq/L.

Source: Dr. O'Toole

PORTLAND, ORE. – Despite common perceptions among medical professionals and the general public, anorexia nervosa is not a psychosocial disease, Julie K. O'Toole, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Rather, it is a brain disorder and should be seen as such, said Dr. O'Toole, medical director of the Kartini Clinic for Disordered Eating, Portland, Ore. She discussed several of the fallacies surrounding anorexia nervosa:

▸ Anorexia nervosa is caused by over-enmeshed mothers. Dr. O'Toole said she has seen no evidence of any single pattern of mothering in her patients. While it may be true that mothers draw closer to their children with anorexia, this is probably a consequence rather than a cause of the disease. Throughout the animal kingdom, mothers draw closer to offspring who are ill or otherwise in danger.

▸ Children choose anorexia to look like models, because of the extreme examples of thinness in the press. The Kartini Clinic treats children who were home-schooled on farms with no television and no access to fashion magazines. Their anorexia is identical to that of other children.

“This is not a volitional disease, andwe find [this explanation] extremely trivializing of a severe brain disorder,” Dr. O'Toole said.

Nevertheless, the dominant images of thinness in the media do make it much harder to get children into remission. Dr. O'Toole likened it to swimming upstream against the prevailing images of what women should look like. But these images are not causal.

▸ Anorexia nervosa is a condition of spoiled, upper-class kids. Several formal epidemiologic studies have failed to find any link between anorexia and social class. At the Kartini Clinic, workers engage in an informal “map epidemiology,” placing a flag corresponding to the homes of their patients in a map of the three counties of Portland. What's striking is the evenness of the distribution, with no concentration of flags in wealthier neighborhoods.

▸ Anorexia nervosa is a condition of white and Western societies. The disease has certainly been seen in non-Westernized Arabic girls, as well as Asians.

“We rarely see African American children in our Oregon practice.

“Yet even if this were the universal experience, and anorexia nervosa were a disease of Westernized whites only, that wouldn't make it a psychosocial disease,” said Dr. O'Toole.

You won't see many whites in a clinic for sickle-cell disease, but that doesn't make that disorder psychosocial in nature, she said.

Likewise, acute lymphocytic leukemia is more common among white children who have middle-class or upper-middle-class backgrounds, but that doesn't make it a psychosocial illness.

▸ Anorexia is all about control. This is the dominant paradigm these days, and even patients will attribute their disease to a need to control one thing in their lives. Dr. O'Toole regards this as too facile an explanation that implies a level of volition that patients only wish that they had.

Moreover, it's dangerous to trust a patient's own explanations of the etiology of her disease, she said. In the 16th century, people with leprosy were likely to attribute their disease to some offense they committed against God, but that didn't make it true.

“I've always been puzzled about why parents cling to the notion that they did something wrong,” Dr. O'Toole commented.

“We tell them, 'You didn't cause this. You couldn't cause this.' We would rather blame ourselves than believe that horrible things could happen to our children, and we are powerless to affect it.”

The Kartini Clinic's opening message is, “We treat children and adolescents in the belief that parents do not cause and children do not choose to have eating disorders.”

Rethinking the purely psychoanalytic model has a number of implications. For one thing, parents can quit blaming themselves, family dysfunction, or careless comments for causing their children's anorexia.

In addition, everyone can stop treating the patient as if it were a volitional disease, and useless “arguing with the disease” can cease. As a brain disorder, anorexia nervosa is not amenable to rational thought.

Furthermore, family and physicians can focus on creating a safe medical environment in which the child can achieve remission and minimize the sequelae of the disease.

Finally, rejecting the purely psychoanalytic paradigm allows the patient to receive the same compassion and understanding as do victims of other medical diseases.

A child with anorexia nervosa should be hospitalized when presenting with certain signs and symptoms. (See box.)

Of course, weight restoration is key, she added.

Selective serotonin reuptake inhibitors are not useful for anorexia nervosa as such but do treat concomitant anxiety, panic, depression, and obsessive-compulsive disorder.

The antipsychotics olanzapine (Zyprexa, 2.5 mg) and risperidone (Risperdal, 0.5 mg) are useful but have side effects including sedation, hyperprolactinemia, type 2 diabetes, and extrapyramidal symptoms. Dr. O'Toole prefers starting with a low dose (25 mg) of Seroquel (quetiapine) at bedtime.

Indications for Hospitalization

▸ Weight less than 75% of the minimum weight for health.

▸ Heart rate less than 45 beats per minute (bpm).

▸ QTc interval greater than 0.444 ms.

▸ Temperature less than 97.3° F (36.3° C).

▸ Decrease in systolic blood pressure from lying to standing of 10 mm Hg or more.

▸ Increase in heart rate from lying to standing after 2.4 minutes of 35 bpm or more.

▸ Potassium level less than 3.0 mEq/L.

Source: Dr. O'Toole

PORTLAND, ORE. – Despite common perceptions among medical professionals and the general public, anorexia nervosa is not a psychosocial disease, Julie K. O'Toole, M.D., said at a conference sponsored by the North Pacific Pediatric Society.

Rather, it is a brain disorder and should be seen as such, said Dr. O'Toole, medical director of the Kartini Clinic for Disordered Eating, Portland, Ore. She discussed several of the fallacies surrounding anorexia nervosa:

▸ Anorexia nervosa is caused by over-enmeshed mothers. Dr. O'Toole said she has seen no evidence of any single pattern of mothering in her patients. While it may be true that mothers draw closer to their children with anorexia, this is probably a consequence rather than a cause of the disease. Throughout the animal kingdom, mothers draw closer to offspring who are ill or otherwise in danger.

▸ Children choose anorexia to look like models, because of the extreme examples of thinness in the press. The Kartini Clinic treats children who were home-schooled on farms with no television and no access to fashion magazines. Their anorexia is identical to that of other children.

“This is not a volitional disease, andwe find [this explanation] extremely trivializing of a severe brain disorder,” Dr. O'Toole said.

Nevertheless, the dominant images of thinness in the media do make it much harder to get children into remission. Dr. O'Toole likened it to swimming upstream against the prevailing images of what women should look like. But these images are not causal.

▸ Anorexia nervosa is a condition of spoiled, upper-class kids. Several formal epidemiologic studies have failed to find any link between anorexia and social class. At the Kartini Clinic, workers engage in an informal “map epidemiology,” placing a flag corresponding to the homes of their patients in a map of the three counties of Portland. What's striking is the evenness of the distribution, with no concentration of flags in wealthier neighborhoods.

▸ Anorexia nervosa is a condition of white and Western societies. The disease has certainly been seen in non-Westernized Arabic girls, as well as Asians.

“We rarely see African American children in our Oregon practice.

“Yet even if this were the universal experience, and anorexia nervosa were a disease of Westernized whites only, that wouldn't make it a psychosocial disease,” said Dr. O'Toole.

You won't see many whites in a clinic for sickle-cell disease, but that doesn't make that disorder psychosocial in nature, she said.

Likewise, acute lymphocytic leukemia is more common among white children who have middle-class or upper-middle-class backgrounds, but that doesn't make it a psychosocial illness.

▸ Anorexia is all about control. This is the dominant paradigm these days, and even patients will attribute their disease to a need to control one thing in their lives. Dr. O'Toole regards this as too facile an explanation that implies a level of volition that patients only wish that they had.

Moreover, it's dangerous to trust a patient's own explanations of the etiology of her disease, she said. In the 16th century, people with leprosy were likely to attribute their disease to some offense they committed against God, but that didn't make it true.

“I've always been puzzled about why parents cling to the notion that they did something wrong,” Dr. O'Toole commented.

“We tell them, 'You didn't cause this. You couldn't cause this.' We would rather blame ourselves than believe that horrible things could happen to our children, and we are powerless to affect it.”

The Kartini Clinic's opening message is, “We treat children and adolescents in the belief that parents do not cause and children do not choose to have eating disorders.”

Rethinking the purely psychoanalytic model has a number of implications. For one thing, parents can quit blaming themselves, family dysfunction, or careless comments for causing their children's anorexia.

In addition, everyone can stop treating the patient as if it were a volitional disease, and useless “arguing with the disease” can cease. As a brain disorder, anorexia nervosa is not amenable to rational thought.

Furthermore, family and physicians can focus on creating a safe medical environment in which the child can achieve remission and minimize the sequelae of the disease.

Finally, rejecting the purely psychoanalytic paradigm allows the patient to receive the same compassion and understanding as do victims of other medical diseases.

A child with anorexia nervosa should be hospitalized when presenting with certain signs and symptoms. (See box.)

Of course, weight restoration is key, she added.

Selective serotonin reuptake inhibitors are not useful for anorexia nervosa as such but do treat concomitant anxiety, panic, depression, and obsessive-compulsive disorder.

The antipsychotics olanzapine (Zyprexa, 2.5 mg) and risperidone (Risperdal, 0.5 mg) are useful but have side effects including sedation, hyperprolactinemia, type 2 diabetes, and extrapyramidal symptoms. Dr. O'Toole prefers starting with a low dose (25 mg) of Seroquel (quetiapine) at bedtime.

Indications for Hospitalization

▸ Weight less than 75% of the minimum weight for health.

▸ Heart rate less than 45 beats per minute (bpm).

▸ QTc interval greater than 0.444 ms.

▸ Temperature less than 97.3° F (36.3° C).

▸ Decrease in systolic blood pressure from lying to standing of 10 mm Hg or more.

▸ Increase in heart rate from lying to standing after 2.4 minutes of 35 bpm or more.

▸ Potassium level less than 3.0 mEq/L.

Source: Dr. O'Toole

SAN FRANCISCO – Extended-release methylphenidate is effective in reducing the symptoms of attention-deficit hyperactivity disorder in adolescents, Linda Pfiffner, Ph.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

The study is significant because few placebo-controlled studies of medication for ADHD in adolescents have been conducted, said Dr. Pfiffner of the university. The randomized, double-blind, placebo-controlled study involved 177 boys and girls, aged 13–18 years, with a confirmed diagnosis of ADHD. During a 4-week, open-label period, the children were titrated to a dose of methylphenidate (Concerta) that resulted in at least a 30% improvement in ADHD symptoms, as rated by the investigators.

They were then randomized to receive placebo or their individualized methylphenidate dose for 2 weeks, after which they were eligible to participate in an 8-week open-label follow-up.

During the titration phase, 36.7% of the children reached a daily dose of 72 mg, the highest dose offered. Smaller proportions of children settled at lower doses: 27.7% at 54 mg, 28.2% at 36 mg, and 7.4% at 18 mg.

At the end of the titration phase, the mean investigator rating of ADHD symptoms fell 86% from baseline.

At the end of the double-blind phase, investigators, parents, and the children themselves independently recorded significant improvements in ADHD symptoms in favor of methylphenidate.

In fact, the patient self-assessments showed a larger difference between the placebo and active medication groups than the investigators or the parents. This suggests that the children may be more sensitive in their judgments of efficacy than the outside observers, Dr. Pfiffner said.

The study was supported by McNeil Consumer & Specialty Pharmaceuticals, which manufactures Concerta.

SAN FRANCISCO – Extended-release methylphenidate is effective in reducing the symptoms of attention-deficit hyperactivity disorder in adolescents, Linda Pfiffner, Ph.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

The study is significant because few placebo-controlled studies of medication for ADHD in adolescents have been conducted, said Dr. Pfiffner of the university. The randomized, double-blind, placebo-controlled study involved 177 boys and girls, aged 13–18 years, with a confirmed diagnosis of ADHD. During a 4-week, open-label period, the children were titrated to a dose of methylphenidate (Concerta) that resulted in at least a 30% improvement in ADHD symptoms, as rated by the investigators.

They were then randomized to receive placebo or their individualized methylphenidate dose for 2 weeks, after which they were eligible to participate in an 8-week open-label follow-up.

During the titration phase, 36.7% of the children reached a daily dose of 72 mg, the highest dose offered. Smaller proportions of children settled at lower doses: 27.7% at 54 mg, 28.2% at 36 mg, and 7.4% at 18 mg.

At the end of the titration phase, the mean investigator rating of ADHD symptoms fell 86% from baseline.

At the end of the double-blind phase, investigators, parents, and the children themselves independently recorded significant improvements in ADHD symptoms in favor of methylphenidate.

In fact, the patient self-assessments showed a larger difference between the placebo and active medication groups than the investigators or the parents. This suggests that the children may be more sensitive in their judgments of efficacy than the outside observers, Dr. Pfiffner said.

The study was supported by McNeil Consumer & Specialty Pharmaceuticals, which manufactures Concerta.

SAN FRANCISCO – Extended-release methylphenidate is effective in reducing the symptoms of attention-deficit hyperactivity disorder in adolescents, Linda Pfiffner, Ph.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

The study is significant because few placebo-controlled studies of medication for ADHD in adolescents have been conducted, said Dr. Pfiffner of the university. The randomized, double-blind, placebo-controlled study involved 177 boys and girls, aged 13–18 years, with a confirmed diagnosis of ADHD. During a 4-week, open-label period, the children were titrated to a dose of methylphenidate (Concerta) that resulted in at least a 30% improvement in ADHD symptoms, as rated by the investigators.

They were then randomized to receive placebo or their individualized methylphenidate dose for 2 weeks, after which they were eligible to participate in an 8-week open-label follow-up.

During the titration phase, 36.7% of the children reached a daily dose of 72 mg, the highest dose offered. Smaller proportions of children settled at lower doses: 27.7% at 54 mg, 28.2% at 36 mg, and 7.4% at 18 mg.

At the end of the titration phase, the mean investigator rating of ADHD symptoms fell 86% from baseline.

At the end of the double-blind phase, investigators, parents, and the children themselves independently recorded significant improvements in ADHD symptoms in favor of methylphenidate.

In fact, the patient self-assessments showed a larger difference between the placebo and active medication groups than the investigators or the parents. This suggests that the children may be more sensitive in their judgments of efficacy than the outside observers, Dr. Pfiffner said.

The study was supported by McNeil Consumer & Specialty Pharmaceuticals, which manufactures Concerta.

SAN FRANCISCO — Hysteroscopic sterilization with Essure microinserts appears safe and effective for at least 5 years after the procedure, according to a poster presented by John F. Kerin, M.D., at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Kerin of Flinders Medical Centre, Adelaide, Australia, and colleagues from the Selective Tubal Occlusion Procedure 2000 Investigators Group followed 643 women for up to 5 years after they underwent the procedure. All women had received bilateral placements of Ensure microinserts as part of phase II or phase III clinical trials sponsored by Conceptus Inc., the device's manufacturer.

Not a single pregnancy occurred in 29,357 woman-months of follow-up, Dr. Kerin reported. The age-adjusted cumulative bayesian effectiveness rate at 5 years was 99.74%.

Patient tolerance, comfort, and satisfaction were measured at seven or eight visits during the follow-up period.

At all visits, 99% of women rated their tolerance of Essure as “good” or “excellent,” 99% rated their comfort as “good” or “excellent,” and 97% rated their satisfaction as “satisfied” or “very satisfied.”

No women reported persistent pain or bleeding.

SAN FRANCISCO — Hysteroscopic sterilization with Essure microinserts appears safe and effective for at least 5 years after the procedure, according to a poster presented by John F. Kerin, M.D., at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Kerin of Flinders Medical Centre, Adelaide, Australia, and colleagues from the Selective Tubal Occlusion Procedure 2000 Investigators Group followed 643 women for up to 5 years after they underwent the procedure. All women had received bilateral placements of Ensure microinserts as part of phase II or phase III clinical trials sponsored by Conceptus Inc., the device's manufacturer.

Not a single pregnancy occurred in 29,357 woman-months of follow-up, Dr. Kerin reported. The age-adjusted cumulative bayesian effectiveness rate at 5 years was 99.74%.

Patient tolerance, comfort, and satisfaction were measured at seven or eight visits during the follow-up period.

At all visits, 99% of women rated their tolerance of Essure as “good” or “excellent,” 99% rated their comfort as “good” or “excellent,” and 97% rated their satisfaction as “satisfied” or “very satisfied.”

No women reported persistent pain or bleeding.

SAN FRANCISCO — Hysteroscopic sterilization with Essure microinserts appears safe and effective for at least 5 years after the procedure, according to a poster presented by John F. Kerin, M.D., at the annual meeting of the American College of Obstetricians and Gynecologists.

Dr. Kerin of Flinders Medical Centre, Adelaide, Australia, and colleagues from the Selective Tubal Occlusion Procedure 2000 Investigators Group followed 643 women for up to 5 years after they underwent the procedure. All women had received bilateral placements of Ensure microinserts as part of phase II or phase III clinical trials sponsored by Conceptus Inc., the device's manufacturer.

Not a single pregnancy occurred in 29,357 woman-months of follow-up, Dr. Kerin reported. The age-adjusted cumulative bayesian effectiveness rate at 5 years was 99.74%.

Patient tolerance, comfort, and satisfaction were measured at seven or eight visits during the follow-up period.

At all visits, 99% of women rated their tolerance of Essure as “good” or “excellent,” 99% rated their comfort as “good” or “excellent,” and 97% rated their satisfaction as “satisfied” or “very satisfied.”

No women reported persistent pain or bleeding.

SAN FRANCISCO — Although some therapies are available for treating chronic viral hepatitis, it remains unclear whether children should be treated, Frank R. Sinatra, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

There are good arguments on both sides of the issue, said Dr. Sinatra, director of the pediatric gastroenterology division at the University of Southern California, Los Angeles.

The arguments for treatment include:

▸ Early treatment can prevent fibrosis and cirrhosis.

▸ Children do at least as well as—and perhaps better than—adults, with current drugs.

▸ Treatment can help prevent the spread of chronic hepatitis B and hepatitis C.

▸ Many clinicians believe any chronic viral infection must be eradicated.

The arguments against treatment include:

▸ Most children with chronic viral hepatitis are asymptomatic. “It's very hard to make an asymptomatic patient feel good,” Dr. Sinatra said.

▸ Fibrosis typically develops slowly.

▸ The side effects from current treatments are significant, and include growth retardation.

▸ Current therapy has a success rate of only 50%.

▸ Even without treatment, a small number of children will experience spontaneous resolution of their chronic infection.

▸ In Dr. Sinatra's view, the best argument against treating children who appear to be doing well is that there are better drugs on the horizon. He knows of at least eight that are in phase I, phase II, or phase III clinical trials.

Whether or not a clinician decides on treatment, these children need to be followed closely for evidence of progressive liver disease and the development of hepatocellular carcinoma, he said.

SAN FRANCISCO — Although some therapies are available for treating chronic viral hepatitis, it remains unclear whether children should be treated, Frank R. Sinatra, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

There are good arguments on both sides of the issue, said Dr. Sinatra, director of the pediatric gastroenterology division at the University of Southern California, Los Angeles.

The arguments for treatment include:

▸ Early treatment can prevent fibrosis and cirrhosis.

▸ Children do at least as well as—and perhaps better than—adults, with current drugs.

▸ Treatment can help prevent the spread of chronic hepatitis B and hepatitis C.

▸ Many clinicians believe any chronic viral infection must be eradicated.

The arguments against treatment include:

▸ Most children with chronic viral hepatitis are asymptomatic. “It's very hard to make an asymptomatic patient feel good,” Dr. Sinatra said.

▸ Fibrosis typically develops slowly.

▸ The side effects from current treatments are significant, and include growth retardation.

▸ Current therapy has a success rate of only 50%.

▸ Even without treatment, a small number of children will experience spontaneous resolution of their chronic infection.

▸ In Dr. Sinatra's view, the best argument against treating children who appear to be doing well is that there are better drugs on the horizon. He knows of at least eight that are in phase I, phase II, or phase III clinical trials.

Whether or not a clinician decides on treatment, these children need to be followed closely for evidence of progressive liver disease and the development of hepatocellular carcinoma, he said.

SAN FRANCISCO — Although some therapies are available for treating chronic viral hepatitis, it remains unclear whether children should be treated, Frank R. Sinatra, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

There are good arguments on both sides of the issue, said Dr. Sinatra, director of the pediatric gastroenterology division at the University of Southern California, Los Angeles.

The arguments for treatment include:

▸ Early treatment can prevent fibrosis and cirrhosis.

▸ Children do at least as well as—and perhaps better than—adults, with current drugs.

▸ Treatment can help prevent the spread of chronic hepatitis B and hepatitis C.

▸ Many clinicians believe any chronic viral infection must be eradicated.

The arguments against treatment include:

▸ Most children with chronic viral hepatitis are asymptomatic. “It's very hard to make an asymptomatic patient feel good,” Dr. Sinatra said.

▸ Fibrosis typically develops slowly.

▸ The side effects from current treatments are significant, and include growth retardation.

▸ Current therapy has a success rate of only 50%.

▸ Even without treatment, a small number of children will experience spontaneous resolution of their chronic infection.

▸ In Dr. Sinatra's view, the best argument against treating children who appear to be doing well is that there are better drugs on the horizon. He knows of at least eight that are in phase I, phase II, or phase III clinical trials.

Whether or not a clinician decides on treatment, these children need to be followed closely for evidence of progressive liver disease and the development of hepatocellular carcinoma, he said.