Sherry Boschert

SAN FRANCISCO — The first prospective, longitudinal study of how cognition in patients with newly diagnosed lupus changes over time produced two surprising findings—that cognitive function is impaired in most patients at the time of diagnosis, but improves dramatically in the 3-4 years after diagnosis.

The study of 113 patients diagnosed at three institutions failed to identify variables to help explain why cognitive function improved over time. Several factors, however, were associated with cognitive dysfunction at baseline—most notably depression, Dr. Michelle Petri said at the annual meeting of the American College of Rheumatology.

“It begs the question of whether we should be doing depression intervention in early lupus,” said Dr. Petri, professor of medicine at Johns Hopkins University, Baltimore. “I can't tell you that depression causes this. It's just as likely that lupus causes depression and lupus causes cognitive dysfunction.”

Several previous prospective studies that looked at patients with established lupus reported that 10 years after diagnosis 80% of patients had measurable cognitive dysfunction. Those studies also reported surprising improvements over time, except perhaps in patients who are persistently anticardiolipin-positive, in whom cognitive function appears to decline over time, Dr. Petri said.

Dr. Petri followed the 113 patients in quarterly visits for 3-4 years. Patients underwent a brain magnetic resonance imaging (MRI) and positron emission tomography (PET) scan at the first and last visits, and were assessed yearly using the ACR neuropsychiatric battery. Every visit included assessments of disease activity, depression, and fatigue; laboratory tests including measures of antiphospholipid antibodies; and measures of nine areas of cognitive function using a computer-assisted battery of tests called Automated Neuropsychological Assessment Metrics (ANAM).

Results showed that 60% of patients at the time of lupus diagnosis had ANAM scores one standard deviation below control patients, and 19% had ANAM scores two or more standard deviations below controls, she said.

ANAM scores improved significantly over time in eight of nine categories—all except simple reaction time, which neither improved nor declined. Gains were seen in vigilance/sustained attention, visual scanning and learning, nonverbal immediate memory, nonverbal delayed memory, visual perception and mental rotation, sustained attention and working memory, simple mental arithmetic, and visuospatial perception and working memory.

The analysis estimated significant improvements in ANAM at 18 and 36 months and significant improvements in results on the ACR neuropsychiatric battery at 12 and 36 months after diagnosis.

Autoantibodies were not associated with changes in cognitive function over time. Neither was smoking status nor the use of prednisone or aspirin at baseline.

Depression at baseline (measured by the Calgary Depression Scale) was associated with problems in visual scanning and learning, vigilance and sustained attention, visuospatial perception and working memory, and sustained attention and working memory.

“This appears to be the most important construct,” she said, though several other baseline measures were associated with smaller numbers of cognitive problems.

The cohort was 97% female, with an average age of 38, and comprised 56% whites, 20% Hispanics, 15% blacks, 5% Asian Americans, and 4% others.

ANAM was developed by the military to assess the effects of chemical agents, extreme environments, and fatigue.

The investigators reported having no conflicts of interest.

'It begs the question of whether we should be doing depression intervention in early lupus.' DR. PETRI

SAN FRANCISCO — The first prospective, longitudinal study of how cognition in patients with newly diagnosed lupus changes over time produced two surprising findings—that cognitive function is impaired in most patients at the time of diagnosis, but improves dramatically in the 3-4 years after diagnosis.

The study of 113 patients diagnosed at three institutions failed to identify variables to help explain why cognitive function improved over time. Several factors, however, were associated with cognitive dysfunction at baseline—most notably depression, Dr. Michelle Petri said at the annual meeting of the American College of Rheumatology.

“It begs the question of whether we should be doing depression intervention in early lupus,” said Dr. Petri, professor of medicine at Johns Hopkins University, Baltimore. “I can't tell you that depression causes this. It's just as likely that lupus causes depression and lupus causes cognitive dysfunction.”

Several previous prospective studies that looked at patients with established lupus reported that 10 years after diagnosis 80% of patients had measurable cognitive dysfunction. Those studies also reported surprising improvements over time, except perhaps in patients who are persistently anticardiolipin-positive, in whom cognitive function appears to decline over time, Dr. Petri said.

Dr. Petri followed the 113 patients in quarterly visits for 3-4 years. Patients underwent a brain magnetic resonance imaging (MRI) and positron emission tomography (PET) scan at the first and last visits, and were assessed yearly using the ACR neuropsychiatric battery. Every visit included assessments of disease activity, depression, and fatigue; laboratory tests including measures of antiphospholipid antibodies; and measures of nine areas of cognitive function using a computer-assisted battery of tests called Automated Neuropsychological Assessment Metrics (ANAM).

Results showed that 60% of patients at the time of lupus diagnosis had ANAM scores one standard deviation below control patients, and 19% had ANAM scores two or more standard deviations below controls, she said.

ANAM scores improved significantly over time in eight of nine categories—all except simple reaction time, which neither improved nor declined. Gains were seen in vigilance/sustained attention, visual scanning and learning, nonverbal immediate memory, nonverbal delayed memory, visual perception and mental rotation, sustained attention and working memory, simple mental arithmetic, and visuospatial perception and working memory.

The analysis estimated significant improvements in ANAM at 18 and 36 months and significant improvements in results on the ACR neuropsychiatric battery at 12 and 36 months after diagnosis.

Autoantibodies were not associated with changes in cognitive function over time. Neither was smoking status nor the use of prednisone or aspirin at baseline.

Depression at baseline (measured by the Calgary Depression Scale) was associated with problems in visual scanning and learning, vigilance and sustained attention, visuospatial perception and working memory, and sustained attention and working memory.

“This appears to be the most important construct,” she said, though several other baseline measures were associated with smaller numbers of cognitive problems.

The cohort was 97% female, with an average age of 38, and comprised 56% whites, 20% Hispanics, 15% blacks, 5% Asian Americans, and 4% others.

ANAM was developed by the military to assess the effects of chemical agents, extreme environments, and fatigue.

The investigators reported having no conflicts of interest.

'It begs the question of whether we should be doing depression intervention in early lupus.' DR. PETRI

SAN FRANCISCO — The first prospective, longitudinal study of how cognition in patients with newly diagnosed lupus changes over time produced two surprising findings—that cognitive function is impaired in most patients at the time of diagnosis, but improves dramatically in the 3-4 years after diagnosis.

The study of 113 patients diagnosed at three institutions failed to identify variables to help explain why cognitive function improved over time. Several factors, however, were associated with cognitive dysfunction at baseline—most notably depression, Dr. Michelle Petri said at the annual meeting of the American College of Rheumatology.

“It begs the question of whether we should be doing depression intervention in early lupus,” said Dr. Petri, professor of medicine at Johns Hopkins University, Baltimore. “I can't tell you that depression causes this. It's just as likely that lupus causes depression and lupus causes cognitive dysfunction.”

Several previous prospective studies that looked at patients with established lupus reported that 10 years after diagnosis 80% of patients had measurable cognitive dysfunction. Those studies also reported surprising improvements over time, except perhaps in patients who are persistently anticardiolipin-positive, in whom cognitive function appears to decline over time, Dr. Petri said.

Dr. Petri followed the 113 patients in quarterly visits for 3-4 years. Patients underwent a brain magnetic resonance imaging (MRI) and positron emission tomography (PET) scan at the first and last visits, and were assessed yearly using the ACR neuropsychiatric battery. Every visit included assessments of disease activity, depression, and fatigue; laboratory tests including measures of antiphospholipid antibodies; and measures of nine areas of cognitive function using a computer-assisted battery of tests called Automated Neuropsychological Assessment Metrics (ANAM).

Results showed that 60% of patients at the time of lupus diagnosis had ANAM scores one standard deviation below control patients, and 19% had ANAM scores two or more standard deviations below controls, she said.

ANAM scores improved significantly over time in eight of nine categories—all except simple reaction time, which neither improved nor declined. Gains were seen in vigilance/sustained attention, visual scanning and learning, nonverbal immediate memory, nonverbal delayed memory, visual perception and mental rotation, sustained attention and working memory, simple mental arithmetic, and visuospatial perception and working memory.

The analysis estimated significant improvements in ANAM at 18 and 36 months and significant improvements in results on the ACR neuropsychiatric battery at 12 and 36 months after diagnosis.

Autoantibodies were not associated with changes in cognitive function over time. Neither was smoking status nor the use of prednisone or aspirin at baseline.

Depression at baseline (measured by the Calgary Depression Scale) was associated with problems in visual scanning and learning, vigilance and sustained attention, visuospatial perception and working memory, and sustained attention and working memory.

“This appears to be the most important construct,” she said, though several other baseline measures were associated with smaller numbers of cognitive problems.

The cohort was 97% female, with an average age of 38, and comprised 56% whites, 20% Hispanics, 15% blacks, 5% Asian Americans, and 4% others.

ANAM was developed by the military to assess the effects of chemical agents, extreme environments, and fatigue.

The investigators reported having no conflicts of interest.

'It begs the question of whether we should be doing depression intervention in early lupus.' DR. PETRI

SAN FRANCISCO — Low-dose colchicine appeared to be as effective as a more conventional dose in treating acute gout flares, but produced far fewer side effects in a randomized, double-blind, placebo-controlled trial in 185 patients.

The results support European League Against Rheumatism 2006 consensus guidelines recommending low doses (0.5 mg t.i.d.) when using colchicine to treat gout flare, a recommendation that was made without the backing of clinical trial data, Dr. Robert A. Terkeltaub said at the annual meeting of the American College of Rheumatology.

The study prerandomized 575 patients to receive high-dose colchicine, low-dose colchicine, or placebo capsules if they called a 24-hour service within 12 hours of the onset of a gout flare. Of the 184 patients who called and received treatment, 52 received high-dose colchicine (1.2 mg, then 0.6 mg hourly for 6 hours, for a total of 4.8 mg); 74 received low-dose colchicine (1.2 mg, then 0.6 mg in 1 hour, for a total of 4.8 mg), and 58 were given placebo (two capsules, then one capsule hourly for 6 hours). One more patient in the placebo group who had no outcomes recorded was excluded from the intent-to-treat analysis of efficacy but included in the safety analysis.

In the only previous placebo-controlled study of colchicine for gout flare, patients on colchicine received a mean total dose of 6.7 mg (higher than the high dose in the current study) and all patients developed diarrhea by the time of clinical response.

In the current study, 33% of patients in the high-dose group and 38% in the low-dose group recorded at least a 50% reduction in pain scores on a seven-point Likert scale within 24 hours of taking the first dose without taking a rescue medication. These rates were significantly higher than the 16% of patients on placebo who achieved this primary outcome. The efficacy between colchicine groups did not differ significantly, said Dr. Terkeltaub, chief of rheumatology in the Veterans Affairs San Diego Healthcare System and professor of medicine at the University of California, San Diego.

The study was funded by Mutual Pharmaceutical Co (a subsidiary of URL Pharma Inc.), which manufacture a colchicine tablet. Based on these results, they are seeking Food and Drug Administration approval of the medication to treat the pain of gout flares.

Dr. Terkeltaub has been a consultant for AR Scientific, the branded arm of URL Pharma, and for other pharmaceutical companies. One of his coinvestigators is an employee and stockholder in AR Scientific, and other associates have been consultants to that company and to others.

High-dose colchicine produced GI side effects at a significantly higher rate (94%), compared with placebo (28%)—especially diarrhea (77% vs. 14%, respectively). In the low-dose colchicine group, 45% had GI side effects and 23% developed diarrhea. These rates were not significantly different, compared with placebo.

In addition, rates of all adverse events, vomiting, severe adverse events, or severe diarrhea were significantly higher in the high-dose group, compared with the placebo group, but did not differ significantly between patients on low-dose colchicine or placebo.

Patients resorted to rescue medications within 24 hours of the first dose at statistically similar rates in the high-dose group (35%) and placebo group (48%), but the rate of rescue in the low-dose group (28%) was significantly lower than in the placebo group.

SAN FRANCISCO — Low-dose colchicine appeared to be as effective as a more conventional dose in treating acute gout flares, but produced far fewer side effects in a randomized, double-blind, placebo-controlled trial in 185 patients.

The results support European League Against Rheumatism 2006 consensus guidelines recommending low doses (0.5 mg t.i.d.) when using colchicine to treat gout flare, a recommendation that was made without the backing of clinical trial data, Dr. Robert A. Terkeltaub said at the annual meeting of the American College of Rheumatology.

The study prerandomized 575 patients to receive high-dose colchicine, low-dose colchicine, or placebo capsules if they called a 24-hour service within 12 hours of the onset of a gout flare. Of the 184 patients who called and received treatment, 52 received high-dose colchicine (1.2 mg, then 0.6 mg hourly for 6 hours, for a total of 4.8 mg); 74 received low-dose colchicine (1.2 mg, then 0.6 mg in 1 hour, for a total of 4.8 mg), and 58 were given placebo (two capsules, then one capsule hourly for 6 hours). One more patient in the placebo group who had no outcomes recorded was excluded from the intent-to-treat analysis of efficacy but included in the safety analysis.

In the only previous placebo-controlled study of colchicine for gout flare, patients on colchicine received a mean total dose of 6.7 mg (higher than the high dose in the current study) and all patients developed diarrhea by the time of clinical response.

In the current study, 33% of patients in the high-dose group and 38% in the low-dose group recorded at least a 50% reduction in pain scores on a seven-point Likert scale within 24 hours of taking the first dose without taking a rescue medication. These rates were significantly higher than the 16% of patients on placebo who achieved this primary outcome. The efficacy between colchicine groups did not differ significantly, said Dr. Terkeltaub, chief of rheumatology in the Veterans Affairs San Diego Healthcare System and professor of medicine at the University of California, San Diego.

The study was funded by Mutual Pharmaceutical Co (a subsidiary of URL Pharma Inc.), which manufacture a colchicine tablet. Based on these results, they are seeking Food and Drug Administration approval of the medication to treat the pain of gout flares.

Dr. Terkeltaub has been a consultant for AR Scientific, the branded arm of URL Pharma, and for other pharmaceutical companies. One of his coinvestigators is an employee and stockholder in AR Scientific, and other associates have been consultants to that company and to others.

High-dose colchicine produced GI side effects at a significantly higher rate (94%), compared with placebo (28%)—especially diarrhea (77% vs. 14%, respectively). In the low-dose colchicine group, 45% had GI side effects and 23% developed diarrhea. These rates were not significantly different, compared with placebo.

In addition, rates of all adverse events, vomiting, severe adverse events, or severe diarrhea were significantly higher in the high-dose group, compared with the placebo group, but did not differ significantly between patients on low-dose colchicine or placebo.

Patients resorted to rescue medications within 24 hours of the first dose at statistically similar rates in the high-dose group (35%) and placebo group (48%), but the rate of rescue in the low-dose group (28%) was significantly lower than in the placebo group.

SAN FRANCISCO — Low-dose colchicine appeared to be as effective as a more conventional dose in treating acute gout flares, but produced far fewer side effects in a randomized, double-blind, placebo-controlled trial in 185 patients.

The results support European League Against Rheumatism 2006 consensus guidelines recommending low doses (0.5 mg t.i.d.) when using colchicine to treat gout flare, a recommendation that was made without the backing of clinical trial data, Dr. Robert A. Terkeltaub said at the annual meeting of the American College of Rheumatology.

The study prerandomized 575 patients to receive high-dose colchicine, low-dose colchicine, or placebo capsules if they called a 24-hour service within 12 hours of the onset of a gout flare. Of the 184 patients who called and received treatment, 52 received high-dose colchicine (1.2 mg, then 0.6 mg hourly for 6 hours, for a total of 4.8 mg); 74 received low-dose colchicine (1.2 mg, then 0.6 mg in 1 hour, for a total of 4.8 mg), and 58 were given placebo (two capsules, then one capsule hourly for 6 hours). One more patient in the placebo group who had no outcomes recorded was excluded from the intent-to-treat analysis of efficacy but included in the safety analysis.

In the only previous placebo-controlled study of colchicine for gout flare, patients on colchicine received a mean total dose of 6.7 mg (higher than the high dose in the current study) and all patients developed diarrhea by the time of clinical response.

In the current study, 33% of patients in the high-dose group and 38% in the low-dose group recorded at least a 50% reduction in pain scores on a seven-point Likert scale within 24 hours of taking the first dose without taking a rescue medication. These rates were significantly higher than the 16% of patients on placebo who achieved this primary outcome. The efficacy between colchicine groups did not differ significantly, said Dr. Terkeltaub, chief of rheumatology in the Veterans Affairs San Diego Healthcare System and professor of medicine at the University of California, San Diego.

The study was funded by Mutual Pharmaceutical Co (a subsidiary of URL Pharma Inc.), which manufacture a colchicine tablet. Based on these results, they are seeking Food and Drug Administration approval of the medication to treat the pain of gout flares.

Dr. Terkeltaub has been a consultant for AR Scientific, the branded arm of URL Pharma, and for other pharmaceutical companies. One of his coinvestigators is an employee and stockholder in AR Scientific, and other associates have been consultants to that company and to others.

High-dose colchicine produced GI side effects at a significantly higher rate (94%), compared with placebo (28%)—especially diarrhea (77% vs. 14%, respectively). In the low-dose colchicine group, 45% had GI side effects and 23% developed diarrhea. These rates were not significantly different, compared with placebo.

In addition, rates of all adverse events, vomiting, severe adverse events, or severe diarrhea were significantly higher in the high-dose group, compared with the placebo group, but did not differ significantly between patients on low-dose colchicine or placebo.

Patients resorted to rescue medications within 24 hours of the first dose at statistically similar rates in the high-dose group (35%) and placebo group (48%), but the rate of rescue in the low-dose group (28%) was significantly lower than in the placebo group.

SAN FRANCISCO — An observational study of 395 patients with suspected early arthritis identified two factors that predicted a diagnosis of rheumatoid arthritis within a year's time.

Patients with swelling in a small joint of the hands and/or feet were six times more likely to be diagnosed with rheumatoid arthritis within a year than were patients whose swollen joints did not include those sites. A diagnosis of rheumatoid arthritis within a year was 39 times more likely in patients whose laboratory tests at baseline showed the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies, compared with anti-CCP-negative patients, Dr. Maria D. Mjaavatten reported at the annual meeting of the American College of Rheumatology.

The same factors also were predictive (though to a lesser degree) of persistent arthritis and of subsequent use of disease-modifying antirheumatic drugs within a year, added Dr. Mjaavatten of the department of rheumatology at Diakonhjemmet Hospital, Oslo.

Patients with small-joint arthritis were twice as likely to develop persistent arthritis and four times as likely to start a DMARD within a year compared with patients without small-joint involvement. Patients with anti-CCP positivity were five times more likely to develop persistent arthritis and nine times more likely to start a DMARD compared with anti-CCP-negative patients.

The results will help inform an ongoing effort by a joint European-American task force to define new diagnostic criteria for early rheumatoid arthritis, Dr. Mjaavatten said. Classification criteria from the American College of Rheumatology (ACR) were developed in 1997 for established disease and are not as useful in early arthritis.

The study enrolled adult patients with at least a 16-week history of one or more clinically swollen joints diagnosed as arthritis by rheumatologists at one of five Norwegian centers, and followed patients for at least a year. Although physicians were aware of the ACR diagnostic criteria for rheumatoid arthritis, diagnoses were not limited to patients who met those criteria.

The cohort represented approximately 70% of all patients enrolled. The other 30% were lost to follow-up before completing at least two follow-up assessments and were presumed to have nonpersistent arthritis. The study defined persistent arthritis as the presence of joint swelling on at least two out of three follow-up assessments during the first year.

The cohort was younger (mean age, 46 years) and included fewer women (57%) than might be expected in a “typical” rheumatoid arthritis cohort, she noted. The mean arthritis duration at baseline was very short (30 days), with a duration of 10 days or less in a quarter of the patients.

During the year of follow-up, 18% of patients were diagnosed with rheumatoid arthritis and 26% had persistent arthritis. At presentation, 38% of patients had single-joint arthritis, 33% had two to four swollen joints, and 29% had polyarthritis.

Dr. Mjaavatten reported no conflicts of interest in this study.

SAN FRANCISCO — An observational study of 395 patients with suspected early arthritis identified two factors that predicted a diagnosis of rheumatoid arthritis within a year's time.

Patients with swelling in a small joint of the hands and/or feet were six times more likely to be diagnosed with rheumatoid arthritis within a year than were patients whose swollen joints did not include those sites. A diagnosis of rheumatoid arthritis within a year was 39 times more likely in patients whose laboratory tests at baseline showed the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies, compared with anti-CCP-negative patients, Dr. Maria D. Mjaavatten reported at the annual meeting of the American College of Rheumatology.

The same factors also were predictive (though to a lesser degree) of persistent arthritis and of subsequent use of disease-modifying antirheumatic drugs within a year, added Dr. Mjaavatten of the department of rheumatology at Diakonhjemmet Hospital, Oslo.

Patients with small-joint arthritis were twice as likely to develop persistent arthritis and four times as likely to start a DMARD within a year compared with patients without small-joint involvement. Patients with anti-CCP positivity were five times more likely to develop persistent arthritis and nine times more likely to start a DMARD compared with anti-CCP-negative patients.

The results will help inform an ongoing effort by a joint European-American task force to define new diagnostic criteria for early rheumatoid arthritis, Dr. Mjaavatten said. Classification criteria from the American College of Rheumatology (ACR) were developed in 1997 for established disease and are not as useful in early arthritis.

The study enrolled adult patients with at least a 16-week history of one or more clinically swollen joints diagnosed as arthritis by rheumatologists at one of five Norwegian centers, and followed patients for at least a year. Although physicians were aware of the ACR diagnostic criteria for rheumatoid arthritis, diagnoses were not limited to patients who met those criteria.

The cohort represented approximately 70% of all patients enrolled. The other 30% were lost to follow-up before completing at least two follow-up assessments and were presumed to have nonpersistent arthritis. The study defined persistent arthritis as the presence of joint swelling on at least two out of three follow-up assessments during the first year.

The cohort was younger (mean age, 46 years) and included fewer women (57%) than might be expected in a “typical” rheumatoid arthritis cohort, she noted. The mean arthritis duration at baseline was very short (30 days), with a duration of 10 days or less in a quarter of the patients.

During the year of follow-up, 18% of patients were diagnosed with rheumatoid arthritis and 26% had persistent arthritis. At presentation, 38% of patients had single-joint arthritis, 33% had two to four swollen joints, and 29% had polyarthritis.

Dr. Mjaavatten reported no conflicts of interest in this study.

SAN FRANCISCO — An observational study of 395 patients with suspected early arthritis identified two factors that predicted a diagnosis of rheumatoid arthritis within a year's time.

Patients with swelling in a small joint of the hands and/or feet were six times more likely to be diagnosed with rheumatoid arthritis within a year than were patients whose swollen joints did not include those sites. A diagnosis of rheumatoid arthritis within a year was 39 times more likely in patients whose laboratory tests at baseline showed the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies, compared with anti-CCP-negative patients, Dr. Maria D. Mjaavatten reported at the annual meeting of the American College of Rheumatology.

The same factors also were predictive (though to a lesser degree) of persistent arthritis and of subsequent use of disease-modifying antirheumatic drugs within a year, added Dr. Mjaavatten of the department of rheumatology at Diakonhjemmet Hospital, Oslo.

Patients with small-joint arthritis were twice as likely to develop persistent arthritis and four times as likely to start a DMARD within a year compared with patients without small-joint involvement. Patients with anti-CCP positivity were five times more likely to develop persistent arthritis and nine times more likely to start a DMARD compared with anti-CCP-negative patients.

The results will help inform an ongoing effort by a joint European-American task force to define new diagnostic criteria for early rheumatoid arthritis, Dr. Mjaavatten said. Classification criteria from the American College of Rheumatology (ACR) were developed in 1997 for established disease and are not as useful in early arthritis.

The study enrolled adult patients with at least a 16-week history of one or more clinically swollen joints diagnosed as arthritis by rheumatologists at one of five Norwegian centers, and followed patients for at least a year. Although physicians were aware of the ACR diagnostic criteria for rheumatoid arthritis, diagnoses were not limited to patients who met those criteria.

The cohort represented approximately 70% of all patients enrolled. The other 30% were lost to follow-up before completing at least two follow-up assessments and were presumed to have nonpersistent arthritis. The study defined persistent arthritis as the presence of joint swelling on at least two out of three follow-up assessments during the first year.

The cohort was younger (mean age, 46 years) and included fewer women (57%) than might be expected in a “typical” rheumatoid arthritis cohort, she noted. The mean arthritis duration at baseline was very short (30 days), with a duration of 10 days or less in a quarter of the patients.

During the year of follow-up, 18% of patients were diagnosed with rheumatoid arthritis and 26% had persistent arthritis. At presentation, 38% of patients had single-joint arthritis, 33% had two to four swollen joints, and 29% had polyarthritis.

Dr. Mjaavatten reported no conflicts of interest in this study.

PHOENIX — Preliminary data on the off-label use of sodium oxybate suggest that it improved sleep in a randomized, placebo-controlled study of 151 patients with fibromyalgia who completed 8 weeks of treatment at 21 medical centers.

The study enrolled 195 patients who were randomized to 8 weeks on sodium oxybate 4.5 g/day or 6 g/day or placebo. Doses were split; patients took a half-dose at bedtime, then awoke 4 hours later for the other half.

Forty-four patients (23%) withdrew before completion, mostly from the higher-dose group and primarily because of side effects, including headache, dizziness, and nausea, Dr. Harvey Moldofsky reported at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Both objective and subjective measures of sleep improved in the drug groups, compared with placebo—for those who finished the study—more so with the 6 g/day dose, said Dr. Moldofsky, president and director of the Centre for Sleep and Chronobiology, Toronto, and professor emeritus of medicine at the University of Toronto. The study was funded by Jazz Pharmaceuticals, the company that makes sodium oxybate. Dr. Moldofsky is a consultant to and an advisory board member for the company.

Many patients with fibromyalgia have sleep disturbances, he noted.

Sleep polysomnography showed significant objective improvements in the high-dose group in the amount of time spent sleeping, in sleep efficiency (the proportion of time spent sleeping, compared with time in bed), and in the amount of deep or slow-wave sleep, he reported.

Subjective results from patient self-reports on several scales showed improvements with either dose, compared with placebo, in pain and fatigue (Visual Analog Scale), daytime sleepiness (Epworth Sleepiness Scale), impaired sleep (Jenkins Scale), and daytime functioning (Functional Outcome of Sleep Questionnaire, SF-36 Vitality scale, and Fibromyalgia Impact Questionnaire).

The study provides a proof of concept, but more research is needed before the drug is used by patients with fibromyalgia, he said.

Besides headache, dizziness, and nausea, other side effects that occurred more frequently in the drug groups than in the placebo group included vomiting, nasopharyngitis, extremity pain, muscle cramp, nervous system disorders, restlessness, and incontinence or other renal/urinary disorders.

In 2002 sodium oxybate was approved in the United States to reduce cataplexy attacks in patients with narcolepsy, but the drug is under tightly restricted distribution from Jazz Pharmaceuticals alone—not from pharmacies. The agent, more commonly known as gamma hydroxybutyrate, or GHB, entered the U.S. market as a dietary supplement in the early 1990s. It subsequently gained favor as a party drug, was used to perpetrate date rape because of its intoxicating effects, and caused many serious adverse events and some deaths from its use and misuse.

More research would be needed to determine whether the improvements in sleep seen in the current study were independent of subjective improvements in pain and functionality, Dr. Moldofsky said.

PHOENIX — Preliminary data on the off-label use of sodium oxybate suggest that it improved sleep in a randomized, placebo-controlled study of 151 patients with fibromyalgia who completed 8 weeks of treatment at 21 medical centers.

The study enrolled 195 patients who were randomized to 8 weeks on sodium oxybate 4.5 g/day or 6 g/day or placebo. Doses were split; patients took a half-dose at bedtime, then awoke 4 hours later for the other half.

Forty-four patients (23%) withdrew before completion, mostly from the higher-dose group and primarily because of side effects, including headache, dizziness, and nausea, Dr. Harvey Moldofsky reported at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Both objective and subjective measures of sleep improved in the drug groups, compared with placebo—for those who finished the study—more so with the 6 g/day dose, said Dr. Moldofsky, president and director of the Centre for Sleep and Chronobiology, Toronto, and professor emeritus of medicine at the University of Toronto. The study was funded by Jazz Pharmaceuticals, the company that makes sodium oxybate. Dr. Moldofsky is a consultant to and an advisory board member for the company.

Many patients with fibromyalgia have sleep disturbances, he noted.

Sleep polysomnography showed significant objective improvements in the high-dose group in the amount of time spent sleeping, in sleep efficiency (the proportion of time spent sleeping, compared with time in bed), and in the amount of deep or slow-wave sleep, he reported.

Subjective results from patient self-reports on several scales showed improvements with either dose, compared with placebo, in pain and fatigue (Visual Analog Scale), daytime sleepiness (Epworth Sleepiness Scale), impaired sleep (Jenkins Scale), and daytime functioning (Functional Outcome of Sleep Questionnaire, SF-36 Vitality scale, and Fibromyalgia Impact Questionnaire).

The study provides a proof of concept, but more research is needed before the drug is used by patients with fibromyalgia, he said.

Besides headache, dizziness, and nausea, other side effects that occurred more frequently in the drug groups than in the placebo group included vomiting, nasopharyngitis, extremity pain, muscle cramp, nervous system disorders, restlessness, and incontinence or other renal/urinary disorders.

In 2002 sodium oxybate was approved in the United States to reduce cataplexy attacks in patients with narcolepsy, but the drug is under tightly restricted distribution from Jazz Pharmaceuticals alone—not from pharmacies. The agent, more commonly known as gamma hydroxybutyrate, or GHB, entered the U.S. market as a dietary supplement in the early 1990s. It subsequently gained favor as a party drug, was used to perpetrate date rape because of its intoxicating effects, and caused many serious adverse events and some deaths from its use and misuse.

More research would be needed to determine whether the improvements in sleep seen in the current study were independent of subjective improvements in pain and functionality, Dr. Moldofsky said.

PHOENIX — Preliminary data on the off-label use of sodium oxybate suggest that it improved sleep in a randomized, placebo-controlled study of 151 patients with fibromyalgia who completed 8 weeks of treatment at 21 medical centers.

The study enrolled 195 patients who were randomized to 8 weeks on sodium oxybate 4.5 g/day or 6 g/day or placebo. Doses were split; patients took a half-dose at bedtime, then awoke 4 hours later for the other half.

Forty-four patients (23%) withdrew before completion, mostly from the higher-dose group and primarily because of side effects, including headache, dizziness, and nausea, Dr. Harvey Moldofsky reported at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Both objective and subjective measures of sleep improved in the drug groups, compared with placebo—for those who finished the study—more so with the 6 g/day dose, said Dr. Moldofsky, president and director of the Centre for Sleep and Chronobiology, Toronto, and professor emeritus of medicine at the University of Toronto. The study was funded by Jazz Pharmaceuticals, the company that makes sodium oxybate. Dr. Moldofsky is a consultant to and an advisory board member for the company.

Many patients with fibromyalgia have sleep disturbances, he noted.

Sleep polysomnography showed significant objective improvements in the high-dose group in the amount of time spent sleeping, in sleep efficiency (the proportion of time spent sleeping, compared with time in bed), and in the amount of deep or slow-wave sleep, he reported.

Subjective results from patient self-reports on several scales showed improvements with either dose, compared with placebo, in pain and fatigue (Visual Analog Scale), daytime sleepiness (Epworth Sleepiness Scale), impaired sleep (Jenkins Scale), and daytime functioning (Functional Outcome of Sleep Questionnaire, SF-36 Vitality scale, and Fibromyalgia Impact Questionnaire).

The study provides a proof of concept, but more research is needed before the drug is used by patients with fibromyalgia, he said.

Besides headache, dizziness, and nausea, other side effects that occurred more frequently in the drug groups than in the placebo group included vomiting, nasopharyngitis, extremity pain, muscle cramp, nervous system disorders, restlessness, and incontinence or other renal/urinary disorders.

In 2002 sodium oxybate was approved in the United States to reduce cataplexy attacks in patients with narcolepsy, but the drug is under tightly restricted distribution from Jazz Pharmaceuticals alone—not from pharmacies. The agent, more commonly known as gamma hydroxybutyrate, or GHB, entered the U.S. market as a dietary supplement in the early 1990s. It subsequently gained favor as a party drug, was used to perpetrate date rape because of its intoxicating effects, and caused many serious adverse events and some deaths from its use and misuse.

More research would be needed to determine whether the improvements in sleep seen in the current study were independent of subjective improvements in pain and functionality, Dr. Moldofsky said.

SAN FRANCISCO — Rheumatologists and primary care physicians tend to use different diagnostic tests and prescribe different treatments for fibromyalgia syndrome, survey results indicated.

A large fraction of physicians in both groups did not follow the American College of Rheumatology (ACR) 1990 criteria for diagnosing fibromyalgia, Dr. Terence W. Starz and his associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

“I don't know what that means,” conceded Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center. “We've got to adhere to criteria” to develop standards of care, he said in an interview during the poster session.

Questionnaires e-mailed to 199 rheumatologists throughout Pennsylvania and 183 primary care physicians in the southwestern portion of the state were returned by 74 (37%) of the rheumatologists and 89 (49%) of the primary care physicians. Both groups agreed that it takes more time to manage patients with fibromyalgia than other patients.

Rheumatologists were significantly more likely to use ACR criteria to diagnose fibromyalgia (56, or 76%) compared with primary care physicians (50, or 56%). The two groups also differed significantly in the use of tests to measure levels of vitamin D, rheumatoid factor, antinuclear antibody, and anti-cyclic citrullinated peptide (anti-CCP) antibody. They reported similar rates of testing for thyroid function, metabolic profile, and human leukocyte antigen B27.

“We need to determine which ones of those should be utilized, because they're very expensive. A vitamin D level can cost up to $250. Anti-CCP is very expensive. They're not included” in the current ACR diagnostic criteria, Dr. Starz said. “We, as a discipline, need to set out standards for diagnosis.”

Vitamin D levels were ordered by 36 rheumatologists (49%) and 15 primary care physicians (17%). Tests for rheumatoid factor were ordered by 43 (58%) and 68 (76%), respectively. Rheumatologists were more likely to measure anti-CCP level (24, or 32%) than were primary care physicians (5, or 6%) but less likely to test for antinuclear antibody (45, or 61%, compared with 68, or 76%, of primary care physicians).

The two groups reported similar perceptions about the pathophysiology of fibromyalgia. Approximately three-fourths said fibromyalgia is both a medical and psychological condition, less than 20% said it's solely a medical condition, and less than 10% said it's solely a psychological condition, judging from the findings in the research, which was recognized as a “notable poster” by the ACR.

Nearly all physicians in both groups prescribed exercise and physical therapy to treat fibromyalgia, but their use of most other therapies differed significantly.

Cognitive therapy was prescribed by 39 rheumatologists (52%) and 26 primary care physicians (29%). NSAIDs were prescribed by 42 (57%) of the rheumatologists and favored by primary care physicians (75, or 84%). “The data on NSAIDs, though, are not very good for fibromyalgia,” Dr. Starz said.

The primary care physicians also were significantly more likely to use SSRIs (68, or 76%) compared with rheumatologists (42, or 57%).

Rheumatologists were more likely to treat with cyclobenzaprine (64, or 86%), or alpha-2-delta ligands such as gabapentin or pregabalin (64, of 86%), compared with primary care physicians (50, or 56% and 59, or 66%, respectively).

The use of selective norepinephrine reuptake inhibitors for fibromyalgia was similar between groups.

“What's interesting to me is there's not nearly enough focus on sleep hygiene and sleep treatment” for patients with fibromyalgia, Dr. Starz commented.

An estimated 5 million people in the United States have fibromyalgia syndrome, more than the combined total of patients with rheumatoid arthritis (1.3 million), systemic lupus erythematosus (322,000), scleroderma (49,000), polymyalgia rheumatica (228,000), and gout (3 million), he said.

The investigators reported no conflicts of interest.

SAN FRANCISCO — Rheumatologists and primary care physicians tend to use different diagnostic tests and prescribe different treatments for fibromyalgia syndrome, survey results indicated.

A large fraction of physicians in both groups did not follow the American College of Rheumatology (ACR) 1990 criteria for diagnosing fibromyalgia, Dr. Terence W. Starz and his associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

“I don't know what that means,” conceded Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center. “We've got to adhere to criteria” to develop standards of care, he said in an interview during the poster session.

Questionnaires e-mailed to 199 rheumatologists throughout Pennsylvania and 183 primary care physicians in the southwestern portion of the state were returned by 74 (37%) of the rheumatologists and 89 (49%) of the primary care physicians. Both groups agreed that it takes more time to manage patients with fibromyalgia than other patients.

Rheumatologists were significantly more likely to use ACR criteria to diagnose fibromyalgia (56, or 76%) compared with primary care physicians (50, or 56%). The two groups also differed significantly in the use of tests to measure levels of vitamin D, rheumatoid factor, antinuclear antibody, and anti-cyclic citrullinated peptide (anti-CCP) antibody. They reported similar rates of testing for thyroid function, metabolic profile, and human leukocyte antigen B27.

“We need to determine which ones of those should be utilized, because they're very expensive. A vitamin D level can cost up to $250. Anti-CCP is very expensive. They're not included” in the current ACR diagnostic criteria, Dr. Starz said. “We, as a discipline, need to set out standards for diagnosis.”

Vitamin D levels were ordered by 36 rheumatologists (49%) and 15 primary care physicians (17%). Tests for rheumatoid factor were ordered by 43 (58%) and 68 (76%), respectively. Rheumatologists were more likely to measure anti-CCP level (24, or 32%) than were primary care physicians (5, or 6%) but less likely to test for antinuclear antibody (45, or 61%, compared with 68, or 76%, of primary care physicians).

The two groups reported similar perceptions about the pathophysiology of fibromyalgia. Approximately three-fourths said fibromyalgia is both a medical and psychological condition, less than 20% said it's solely a medical condition, and less than 10% said it's solely a psychological condition, judging from the findings in the research, which was recognized as a “notable poster” by the ACR.

Nearly all physicians in both groups prescribed exercise and physical therapy to treat fibromyalgia, but their use of most other therapies differed significantly.

Cognitive therapy was prescribed by 39 rheumatologists (52%) and 26 primary care physicians (29%). NSAIDs were prescribed by 42 (57%) of the rheumatologists and favored by primary care physicians (75, or 84%). “The data on NSAIDs, though, are not very good for fibromyalgia,” Dr. Starz said.

The primary care physicians also were significantly more likely to use SSRIs (68, or 76%) compared with rheumatologists (42, or 57%).

Rheumatologists were more likely to treat with cyclobenzaprine (64, or 86%), or alpha-2-delta ligands such as gabapentin or pregabalin (64, of 86%), compared with primary care physicians (50, or 56% and 59, or 66%, respectively).

The use of selective norepinephrine reuptake inhibitors for fibromyalgia was similar between groups.

“What's interesting to me is there's not nearly enough focus on sleep hygiene and sleep treatment” for patients with fibromyalgia, Dr. Starz commented.

An estimated 5 million people in the United States have fibromyalgia syndrome, more than the combined total of patients with rheumatoid arthritis (1.3 million), systemic lupus erythematosus (322,000), scleroderma (49,000), polymyalgia rheumatica (228,000), and gout (3 million), he said.

The investigators reported no conflicts of interest.

SAN FRANCISCO — Rheumatologists and primary care physicians tend to use different diagnostic tests and prescribe different treatments for fibromyalgia syndrome, survey results indicated.

A large fraction of physicians in both groups did not follow the American College of Rheumatology (ACR) 1990 criteria for diagnosing fibromyalgia, Dr. Terence W. Starz and his associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.

“I don't know what that means,” conceded Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center. “We've got to adhere to criteria” to develop standards of care, he said in an interview during the poster session.

Questionnaires e-mailed to 199 rheumatologists throughout Pennsylvania and 183 primary care physicians in the southwestern portion of the state were returned by 74 (37%) of the rheumatologists and 89 (49%) of the primary care physicians. Both groups agreed that it takes more time to manage patients with fibromyalgia than other patients.

Rheumatologists were significantly more likely to use ACR criteria to diagnose fibromyalgia (56, or 76%) compared with primary care physicians (50, or 56%). The two groups also differed significantly in the use of tests to measure levels of vitamin D, rheumatoid factor, antinuclear antibody, and anti-cyclic citrullinated peptide (anti-CCP) antibody. They reported similar rates of testing for thyroid function, metabolic profile, and human leukocyte antigen B27.

“We need to determine which ones of those should be utilized, because they're very expensive. A vitamin D level can cost up to $250. Anti-CCP is very expensive. They're not included” in the current ACR diagnostic criteria, Dr. Starz said. “We, as a discipline, need to set out standards for diagnosis.”

Vitamin D levels were ordered by 36 rheumatologists (49%) and 15 primary care physicians (17%). Tests for rheumatoid factor were ordered by 43 (58%) and 68 (76%), respectively. Rheumatologists were more likely to measure anti-CCP level (24, or 32%) than were primary care physicians (5, or 6%) but less likely to test for antinuclear antibody (45, or 61%, compared with 68, or 76%, of primary care physicians).

The two groups reported similar perceptions about the pathophysiology of fibromyalgia. Approximately three-fourths said fibromyalgia is both a medical and psychological condition, less than 20% said it's solely a medical condition, and less than 10% said it's solely a psychological condition, judging from the findings in the research, which was recognized as a “notable poster” by the ACR.

Nearly all physicians in both groups prescribed exercise and physical therapy to treat fibromyalgia, but their use of most other therapies differed significantly.

Cognitive therapy was prescribed by 39 rheumatologists (52%) and 26 primary care physicians (29%). NSAIDs were prescribed by 42 (57%) of the rheumatologists and favored by primary care physicians (75, or 84%). “The data on NSAIDs, though, are not very good for fibromyalgia,” Dr. Starz said.

The primary care physicians also were significantly more likely to use SSRIs (68, or 76%) compared with rheumatologists (42, or 57%).

Rheumatologists were more likely to treat with cyclobenzaprine (64, or 86%), or alpha-2-delta ligands such as gabapentin or pregabalin (64, of 86%), compared with primary care physicians (50, or 56% and 59, or 66%, respectively).

The use of selective norepinephrine reuptake inhibitors for fibromyalgia was similar between groups.

“What's interesting to me is there's not nearly enough focus on sleep hygiene and sleep treatment” for patients with fibromyalgia, Dr. Starz commented.

An estimated 5 million people in the United States have fibromyalgia syndrome, more than the combined total of patients with rheumatoid arthritis (1.3 million), systemic lupus erythematosus (322,000), scleroderma (49,000), polymyalgia rheumatica (228,000), and gout (3 million), he said.

The investigators reported no conflicts of interest.

Diagnosis: Orf

The patient worked in an office but lived 20 miles from a major city and denied any contact with the sheep, goats, or cattle that are present in her farming community.

She originally sought care from her primary care physician, who treated her with azithromycin and trimethoprim-sulfamethoxazole, but the lesion worsened, Dr. Jason Hadley said in a poster presentation at the annual meeting of the American Society of Dermatopathology.

A skin swab grew only normal skin flora. Bartonella serologies were negative.

She was referred to Dr. Hadley and his associates in the dermatology department at the University of Utah, Salt Lake City. "When you have an enlarging, red, edematous plaque on the hand, you need to think of infectious causes," he said.

The clinical differential diagnoses included cutaneous anthrax, cat scratch disease, tularemia, orf, and milker's nodule.

The feral kitten scratch became a painful blister that eventually ulcerated because of infection. The histopathology of orf and milker's nodule are nearly identical, but orf is more likely to ulcerate or necrose, he said.

A skin biopsy showed features of orf: prominent spongiotic subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. There was overlying parakeratosis with serum. Seen on higher power, epidermal cells were enlarged and had a prominent glassy appearance with apoptotic keratinocytes and enlarged nuclei with occasional mitotic figures. Numerous cytoplasmic inclusions characteristic of orf were seen in keratinocytes.

Dr. Hadley and his associates assumed the patient had orf infection because of the nature of the ulcerated lesion and the pathology findings, though the specific viral type could not be identified. Only a polymerase chain reaction test of fresh vesicle fluid or debris could have distinguished orf from milker's nodule.

Orf virus is a Parapoxvirus that typically infects sheep and goats and has been known to be transmitted to humans through bites from those animals or skin contact with fomites in fence posts.

"To our knowledge, this is the first time that there is a well-documented case of it being transmitted by a cat scratch," she said.

Orf lesions heal spontaneously in immunocompetent people but can get large and fail to heal in immunocompromised people. Because this patient's methotrexate therapy caused immunosuppression, her psoriasis medication was stopped and she was treated with imiquimod 5% cream applied daily to the lesion. After 10 weeks of treatment, the lesion healed completely with no scar, and her psoriasis medication was restarted. She has not had a recurrence of the orf lesion.

Orf is uncommon in the United States but more frequent elsewhere.

The patient had complete healing after treatment with imiquimod 5% cream.

A histologic image shows prominent spongiotic epidermis with subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. Photos courtesy Dr. Jason Hadley

Diagnosis: Orf

The patient worked in an office but lived 20 miles from a major city and denied any contact with the sheep, goats, or cattle that are present in her farming community.

She originally sought care from her primary care physician, who treated her with azithromycin and trimethoprim-sulfamethoxazole, but the lesion worsened, Dr. Jason Hadley said in a poster presentation at the annual meeting of the American Society of Dermatopathology.

A skin swab grew only normal skin flora. Bartonella serologies were negative.

She was referred to Dr. Hadley and his associates in the dermatology department at the University of Utah, Salt Lake City. "When you have an enlarging, red, edematous plaque on the hand, you need to think of infectious causes," he said.

The clinical differential diagnoses included cutaneous anthrax, cat scratch disease, tularemia, orf, and milker's nodule.

The feral kitten scratch became a painful blister that eventually ulcerated because of infection. The histopathology of orf and milker's nodule are nearly identical, but orf is more likely to ulcerate or necrose, he said.

A skin biopsy showed features of orf: prominent spongiotic subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. There was overlying parakeratosis with serum. Seen on higher power, epidermal cells were enlarged and had a prominent glassy appearance with apoptotic keratinocytes and enlarged nuclei with occasional mitotic figures. Numerous cytoplasmic inclusions characteristic of orf were seen in keratinocytes.

Dr. Hadley and his associates assumed the patient had orf infection because of the nature of the ulcerated lesion and the pathology findings, though the specific viral type could not be identified. Only a polymerase chain reaction test of fresh vesicle fluid or debris could have distinguished orf from milker's nodule.

Orf virus is a Parapoxvirus that typically infects sheep and goats and has been known to be transmitted to humans through bites from those animals or skin contact with fomites in fence posts.

"To our knowledge, this is the first time that there is a well-documented case of it being transmitted by a cat scratch," she said.

Orf lesions heal spontaneously in immunocompetent people but can get large and fail to heal in immunocompromised people. Because this patient's methotrexate therapy caused immunosuppression, her psoriasis medication was stopped and she was treated with imiquimod 5% cream applied daily to the lesion. After 10 weeks of treatment, the lesion healed completely with no scar, and her psoriasis medication was restarted. She has not had a recurrence of the orf lesion.

Orf is uncommon in the United States but more frequent elsewhere.

The patient had complete healing after treatment with imiquimod 5% cream.

A histologic image shows prominent spongiotic epidermis with subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. Photos courtesy Dr. Jason Hadley

Diagnosis: Orf

The patient worked in an office but lived 20 miles from a major city and denied any contact with the sheep, goats, or cattle that are present in her farming community.

She originally sought care from her primary care physician, who treated her with azithromycin and trimethoprim-sulfamethoxazole, but the lesion worsened, Dr. Jason Hadley said in a poster presentation at the annual meeting of the American Society of Dermatopathology.

A skin swab grew only normal skin flora. Bartonella serologies were negative.

She was referred to Dr. Hadley and his associates in the dermatology department at the University of Utah, Salt Lake City. "When you have an enlarging, red, edematous plaque on the hand, you need to think of infectious causes," he said.

The clinical differential diagnoses included cutaneous anthrax, cat scratch disease, tularemia, orf, and milker's nodule.

The feral kitten scratch became a painful blister that eventually ulcerated because of infection. The histopathology of orf and milker's nodule are nearly identical, but orf is more likely to ulcerate or necrose, he said.

A skin biopsy showed features of orf: prominent spongiotic subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. There was overlying parakeratosis with serum. Seen on higher power, epidermal cells were enlarged and had a prominent glassy appearance with apoptotic keratinocytes and enlarged nuclei with occasional mitotic figures. Numerous cytoplasmic inclusions characteristic of orf were seen in keratinocytes.

Dr. Hadley and his associates assumed the patient had orf infection because of the nature of the ulcerated lesion and the pathology findings, though the specific viral type could not be identified. Only a polymerase chain reaction test of fresh vesicle fluid or debris could have distinguished orf from milker's nodule.

Orf virus is a Parapoxvirus that typically infects sheep and goats and has been known to be transmitted to humans through bites from those animals or skin contact with fomites in fence posts.

"To our knowledge, this is the first time that there is a well-documented case of it being transmitted by a cat scratch," she said.

Orf lesions heal spontaneously in immunocompetent people but can get large and fail to heal in immunocompromised people. Because this patient's methotrexate therapy caused immunosuppression, her psoriasis medication was stopped and she was treated with imiquimod 5% cream applied daily to the lesion. After 10 weeks of treatment, the lesion healed completely with no scar, and her psoriasis medication was restarted. She has not had a recurrence of the orf lesion.

Orf is uncommon in the United States but more frequent elsewhere.

The patient had complete healing after treatment with imiquimod 5% cream.

A histologic image shows prominent spongiotic epidermis with subcorneal vesiculation and a mixed inflammatory response of lymphocytes, histiocyte-like cells, and neutrophils. Photos courtesy Dr. Jason Hadley

SAN FRANCISCO — Histopathologic features of scalp nevi in children and adolescents that overlap with features of Clark's or dysplastic nevi also can be seen in scalp nevi in young adults, results of a study of 89 hairline and scalp nevi found.

The features may trigger melanoma concerns, so it is important to be aware of them to improve diagnostic accuracy and prevent unnecessary concerns or overtreatment, Dr. Betsy N. Perry said at the annual meeting of the American Society of Dermatopathology.

The nevi in this review came from 84 patients (ages 3–35 years) whose samples were filed in the dermatopathology service at the University of California, San Francisco. They showed characteristics common to other "nevi of special sites" such as melanocytic nevi on acral surfaces, genitalia, flexural areas, the breast, and in and around the ear, she and her associates reported.

In 63 (95%) nevi from 66 children and adolescents (aged 3–18 years) and in 19 (83%) of 23 nevi from young adults (aged 19–35 years), the lesions contained large nests of cells that were composed primarily of pigmented epithelioid melanocytes and/or were distributed irregularly along the dermal-epidermal junction. More often than not, the melanocytes extended onto hair follicles and other adnexal structures in large nests or singly or in small clusters. Adnexal involvement was seen in 44 nevi (67%) from children/adolescents and 14 (61%) from young adults.

The findings support previous reports of these characteristics in scalp nevi of children and adolescents. "These are also seen in young adults, which is something that was not really clear in the literature before," said Dr. Perry of the University of Utah, Salt Lake City.

Suprabasilar scatter was rare, and seen in five (8%) nevi in children and adolescents and in none of the nevi from adults.

Among architectural features, squaring or bridging of the rete was common. Squaring was seen in 51 nevi (77%) in children/adolescents and 22 nevi (96%) in adults, and bridging was found in 61 nevi (92%) in children/adolescents and 20 (87%) in adults. "In some of the lesions, a concomitant congenital pattern was appreciated" in 25 (38%) of nevi in children/adolescents and in 5 (22%) in adults, she said.

Epithelioid melanocytes were very common, and appeared in 64 (97%) of nevi from children/adolescents and 22 (96%) from adults, Dr. Perry emphasized. Other cytologic features included atypical melanocytes in only three (5%) of nevi in children/adolescents and in none from adults.

"When cytologic atypia occurred, it was rare, and could either be in the epidermal or the dermal component," she said.

Dusty melanin commonly was present within keratinocytes, which is not known to have clinical significance but as a practical matter can make it difficult to determine circumscription and to look for melanocytes within these lesions, she added. In 33 (50%) of nevi from children/adolescents and 15 (65%) from adults, dusty melanin was present in keratinocytes.

Stromal features that were observed in most samples included lamellar fibrosis in 62 nevi (94%) from children/adolescents and in all nevi from adults. Lymphocytic infiltrate was seen in 55 nevi (83%) from children/adolescents and in 16 (70%) from adults. Melanophages appeared in 58 nevi (88%) from children/adolescents and in 18 (78%) from adults.

All nevi in the study had been removed from patients because they appeared clinically atypical.

These findings support results of two 2001 studies that characterized scalp nevi in children and adolescents and showed that they share features with "nevi of special sites."

A more recent analysis of atypical nevi of the scalp found features that were not commonly ascribed to either Clark's or "dysplastic" nevi in 4 (10%) of 39 nevi from adolescents but not in 30 nevi from children or 160 nevi from adults (J. Cutan. Pathol. 2007;34:365–9).

SAN FRANCISCO — Histopathologic features of scalp nevi in children and adolescents that overlap with features of Clark's or dysplastic nevi also can be seen in scalp nevi in young adults, results of a study of 89 hairline and scalp nevi found.

The features may trigger melanoma concerns, so it is important to be aware of them to improve diagnostic accuracy and prevent unnecessary concerns or overtreatment, Dr. Betsy N. Perry said at the annual meeting of the American Society of Dermatopathology.

The nevi in this review came from 84 patients (ages 3–35 years) whose samples were filed in the dermatopathology service at the University of California, San Francisco. They showed characteristics common to other "nevi of special sites" such as melanocytic nevi on acral surfaces, genitalia, flexural areas, the breast, and in and around the ear, she and her associates reported.

In 63 (95%) nevi from 66 children and adolescents (aged 3–18 years) and in 19 (83%) of 23 nevi from young adults (aged 19–35 years), the lesions contained large nests of cells that were composed primarily of pigmented epithelioid melanocytes and/or were distributed irregularly along the dermal-epidermal junction. More often than not, the melanocytes extended onto hair follicles and other adnexal structures in large nests or singly or in small clusters. Adnexal involvement was seen in 44 nevi (67%) from children/adolescents and 14 (61%) from young adults.

The findings support previous reports of these characteristics in scalp nevi of children and adolescents. "These are also seen in young adults, which is something that was not really clear in the literature before," said Dr. Perry of the University of Utah, Salt Lake City.

Suprabasilar scatter was rare, and seen in five (8%) nevi in children and adolescents and in none of the nevi from adults.

Among architectural features, squaring or bridging of the rete was common. Squaring was seen in 51 nevi (77%) in children/adolescents and 22 nevi (96%) in adults, and bridging was found in 61 nevi (92%) in children/adolescents and 20 (87%) in adults. "In some of the lesions, a concomitant congenital pattern was appreciated" in 25 (38%) of nevi in children/adolescents and in 5 (22%) in adults, she said.

Epithelioid melanocytes were very common, and appeared in 64 (97%) of nevi from children/adolescents and 22 (96%) from adults, Dr. Perry emphasized. Other cytologic features included atypical melanocytes in only three (5%) of nevi in children/adolescents and in none from adults.

"When cytologic atypia occurred, it was rare, and could either be in the epidermal or the dermal component," she said.

Dusty melanin commonly was present within keratinocytes, which is not known to have clinical significance but as a practical matter can make it difficult to determine circumscription and to look for melanocytes within these lesions, she added. In 33 (50%) of nevi from children/adolescents and 15 (65%) from adults, dusty melanin was present in keratinocytes.

Stromal features that were observed in most samples included lamellar fibrosis in 62 nevi (94%) from children/adolescents and in all nevi from adults. Lymphocytic infiltrate was seen in 55 nevi (83%) from children/adolescents and in 16 (70%) from adults. Melanophages appeared in 58 nevi (88%) from children/adolescents and in 18 (78%) from adults.

All nevi in the study had been removed from patients because they appeared clinically atypical.

These findings support results of two 2001 studies that characterized scalp nevi in children and adolescents and showed that they share features with "nevi of special sites."

A more recent analysis of atypical nevi of the scalp found features that were not commonly ascribed to either Clark's or "dysplastic" nevi in 4 (10%) of 39 nevi from adolescents but not in 30 nevi from children or 160 nevi from adults (J. Cutan. Pathol. 2007;34:365–9).

SAN FRANCISCO — Histopathologic features of scalp nevi in children and adolescents that overlap with features of Clark's or dysplastic nevi also can be seen in scalp nevi in young adults, results of a study of 89 hairline and scalp nevi found.

The features may trigger melanoma concerns, so it is important to be aware of them to improve diagnostic accuracy and prevent unnecessary concerns or overtreatment, Dr. Betsy N. Perry said at the annual meeting of the American Society of Dermatopathology.

The nevi in this review came from 84 patients (ages 3–35 years) whose samples were filed in the dermatopathology service at the University of California, San Francisco. They showed characteristics common to other "nevi of special sites" such as melanocytic nevi on acral surfaces, genitalia, flexural areas, the breast, and in and around the ear, she and her associates reported.

In 63 (95%) nevi from 66 children and adolescents (aged 3–18 years) and in 19 (83%) of 23 nevi from young adults (aged 19–35 years), the lesions contained large nests of cells that were composed primarily of pigmented epithelioid melanocytes and/or were distributed irregularly along the dermal-epidermal junction. More often than not, the melanocytes extended onto hair follicles and other adnexal structures in large nests or singly or in small clusters. Adnexal involvement was seen in 44 nevi (67%) from children/adolescents and 14 (61%) from young adults.

The findings support previous reports of these characteristics in scalp nevi of children and adolescents. "These are also seen in young adults, which is something that was not really clear in the literature before," said Dr. Perry of the University of Utah, Salt Lake City.

Suprabasilar scatter was rare, and seen in five (8%) nevi in children and adolescents and in none of the nevi from adults.

Among architectural features, squaring or bridging of the rete was common. Squaring was seen in 51 nevi (77%) in children/adolescents and 22 nevi (96%) in adults, and bridging was found in 61 nevi (92%) in children/adolescents and 20 (87%) in adults. "In some of the lesions, a concomitant congenital pattern was appreciated" in 25 (38%) of nevi in children/adolescents and in 5 (22%) in adults, she said.

Epithelioid melanocytes were very common, and appeared in 64 (97%) of nevi from children/adolescents and 22 (96%) from adults, Dr. Perry emphasized. Other cytologic features included atypical melanocytes in only three (5%) of nevi in children/adolescents and in none from adults.

"When cytologic atypia occurred, it was rare, and could either be in the epidermal or the dermal component," she said.

Dusty melanin commonly was present within keratinocytes, which is not known to have clinical significance but as a practical matter can make it difficult to determine circumscription and to look for melanocytes within these lesions, she added. In 33 (50%) of nevi from children/adolescents and 15 (65%) from adults, dusty melanin was present in keratinocytes.

Stromal features that were observed in most samples included lamellar fibrosis in 62 nevi (94%) from children/adolescents and in all nevi from adults. Lymphocytic infiltrate was seen in 55 nevi (83%) from children/adolescents and in 16 (70%) from adults. Melanophages appeared in 58 nevi (88%) from children/adolescents and in 18 (78%) from adults.

All nevi in the study had been removed from patients because they appeared clinically atypical.

These findings support results of two 2001 studies that characterized scalp nevi in children and adolescents and showed that they share features with "nevi of special sites."

A more recent analysis of atypical nevi of the scalp found features that were not commonly ascribed to either Clark's or "dysplastic" nevi in 4 (10%) of 39 nevi from adolescents but not in 30 nevi from children or 160 nevi from adults (J. Cutan. Pathol. 2007;34:365–9).

STANFORD, CALIF. — If a young child exhibits both global developmental delay and stripes or swirls of skin hypopigmentation on the trunk, get a peripheral blood sample for chromosome analysis.

Hypomelanosis of Ito presents as developmental delay plus swirls or patches of hypopigmentation or depigmentation along the lines of Blaschko, Dr. Louanne Hudgins said at a pediatric update that was sponsored by Stanford University.

Blaschko's lines are a nonrandom cutaneous distribution pattern of pigment anomalies caused by migration of skin cells that is believed to start during embryogenesis, she explained.

About half of the people with hypomelanosis of Ito will show chromosomal mosaicism, which means that there is more than one cell line in the chromosomes. The skin lesions and developmental delay plus chromosomal mosaicism clinch the diagnosis of this rare disorder, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

Making the diagnosis explains both the skin findings and the developmental delay and eliminates the need for any further workup to find the cause of either problem, she noted.

The diagnosis also can give parents information about the risk for recurrence. Chromosomal mosaicism indicates that a normal cell line is present and that the abnormal cell line probably developed after fertilization took place. "The likelihood that parents would have another child like this would be low," she said.

From 40% to 60% of patients with hypomelanosis of Ito will have structural brain abnormalities or mental retardation with or without seizures.

This risk is the same in all patients with hypomelanosis of Ito, regardless of whether they have chromosome abnormalities or normal karyotypes.

Although the skin lesions can be present at birth, "most of the cases I've seen did not become apparent until later in childhood—around 18 months to 3 years," said Dr. Hudgins, who reported having no conflicts of interest.

If it is not possible to get a peripheral blood sample, take a skin biopsy, preferably from an area bordering both hypopigmented and hyperpigmented cells, she advised. Send the sample to the cytogenetics lab, which will grow the fibroblasts and then analyze chromosomes from the fibroblasts.

If hypomelanosis of Ito is suspected because of skin lesions but the child is meeting developmental milestones, there's no need to do a genetic workup for this disorder, she said.

Marbled hypopigmented swirls or patches can be seen on the abdomens of patients who have hypomelanosis of Ito. ©Elsevier, Kliegman: Nelson Textbook of Pediatrics, 18th ed., Hypopigmented Lesions, Chapter 652, 2007

STANFORD, CALIF. — If a young child exhibits both global developmental delay and stripes or swirls of skin hypopigmentation on the trunk, get a peripheral blood sample for chromosome analysis.

Hypomelanosis of Ito presents as developmental delay plus swirls or patches of hypopigmentation or depigmentation along the lines of Blaschko, Dr. Louanne Hudgins said at a pediatric update that was sponsored by Stanford University.

Blaschko's lines are a nonrandom cutaneous distribution pattern of pigment anomalies caused by migration of skin cells that is believed to start during embryogenesis, she explained.

About half of the people with hypomelanosis of Ito will show chromosomal mosaicism, which means that there is more than one cell line in the chromosomes. The skin lesions and developmental delay plus chromosomal mosaicism clinch the diagnosis of this rare disorder, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

Making the diagnosis explains both the skin findings and the developmental delay and eliminates the need for any further workup to find the cause of either problem, she noted.

The diagnosis also can give parents information about the risk for recurrence. Chromosomal mosaicism indicates that a normal cell line is present and that the abnormal cell line probably developed after fertilization took place. "The likelihood that parents would have another child like this would be low," she said.

From 40% to 60% of patients with hypomelanosis of Ito will have structural brain abnormalities or mental retardation with or without seizures.

This risk is the same in all patients with hypomelanosis of Ito, regardless of whether they have chromosome abnormalities or normal karyotypes.

Although the skin lesions can be present at birth, "most of the cases I've seen did not become apparent until later in childhood—around 18 months to 3 years," said Dr. Hudgins, who reported having no conflicts of interest.

If it is not possible to get a peripheral blood sample, take a skin biopsy, preferably from an area bordering both hypopigmented and hyperpigmented cells, she advised. Send the sample to the cytogenetics lab, which will grow the fibroblasts and then analyze chromosomes from the fibroblasts.

If hypomelanosis of Ito is suspected because of skin lesions but the child is meeting developmental milestones, there's no need to do a genetic workup for this disorder, she said.

Marbled hypopigmented swirls or patches can be seen on the abdomens of patients who have hypomelanosis of Ito. ©Elsevier, Kliegman: Nelson Textbook of Pediatrics, 18th ed., Hypopigmented Lesions, Chapter 652, 2007

STANFORD, CALIF. — If a young child exhibits both global developmental delay and stripes or swirls of skin hypopigmentation on the trunk, get a peripheral blood sample for chromosome analysis.

Hypomelanosis of Ito presents as developmental delay plus swirls or patches of hypopigmentation or depigmentation along the lines of Blaschko, Dr. Louanne Hudgins said at a pediatric update that was sponsored by Stanford University.

Blaschko's lines are a nonrandom cutaneous distribution pattern of pigment anomalies caused by migration of skin cells that is believed to start during embryogenesis, she explained.

About half of the people with hypomelanosis of Ito will show chromosomal mosaicism, which means that there is more than one cell line in the chromosomes. The skin lesions and developmental delay plus chromosomal mosaicism clinch the diagnosis of this rare disorder, said Dr. Hudgins, professor of pediatrics and chief of medical genetics at Stanford.

Making the diagnosis explains both the skin findings and the developmental delay and eliminates the need for any further workup to find the cause of either problem, she noted.

The diagnosis also can give parents information about the risk for recurrence. Chromosomal mosaicism indicates that a normal cell line is present and that the abnormal cell line probably developed after fertilization took place. "The likelihood that parents would have another child like this would be low," she said.

From 40% to 60% of patients with hypomelanosis of Ito will have structural brain abnormalities or mental retardation with or without seizures.

This risk is the same in all patients with hypomelanosis of Ito, regardless of whether they have chromosome abnormalities or normal karyotypes.

Although the skin lesions can be present at birth, "most of the cases I've seen did not become apparent until later in childhood—around 18 months to 3 years," said Dr. Hudgins, who reported having no conflicts of interest.

If it is not possible to get a peripheral blood sample, take a skin biopsy, preferably from an area bordering both hypopigmented and hyperpigmented cells, she advised. Send the sample to the cytogenetics lab, which will grow the fibroblasts and then analyze chromosomes from the fibroblasts.

If hypomelanosis of Ito is suspected because of skin lesions but the child is meeting developmental milestones, there's no need to do a genetic workup for this disorder, she said.

Marbled hypopigmented swirls or patches can be seen on the abdomens of patients who have hypomelanosis of Ito. ©Elsevier, Kliegman: Nelson Textbook of Pediatrics, 18th ed., Hypopigmented Lesions, Chapter 652, 2007

PHOENIX — Flexibility in scheduling would help depressed women access cognitive-behavioral therapy during or just after pregnancy, a survey of 24 women found. A little more respect would be nice too, respondents said.

Results of the qualitative survey informed a revision of a cognitive-behavioral treatment manual that will be tested in a randomized, controlled trial with 60 women comparing the revised therapy model with treatment as usual, Heather A. Flynn, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

She and her associates used the Edinburgh Postnatal Depression Scale to screen 274 pregnant or postpartum women in the waiting rooms of five obstetrics clinics. The Structured Clinical Interview for DSM Disorders identified 24 of these women, who completed a questionnaire about their preferences for receiving cognitive-behavioral therapy, with major depressive disorder or minor depression. The women said they would prefer to get CBT in an obstetrician's office or at home by telephone. Postpartum women said that having child care available at the clinic would be a big help. “We're actually doing that now,” said Dr. Flynn, an assistant professor of psychiatry at the University of Michigan, Ann Arbor.

All 24 women spontaneously reported that they have felt judged, disrespected, or stigmatized by health care workers. “Women did not feel that they were listened to” as they tried to get help, she said.

The women did not acknowledge that what they were experiencing was depression, however, and did not want therapy to be presented as treatment for depression. “The way you present treatment is very important,” Dr. Flynn suggested.

The investigators preliminarily tested an eight-session program of CBT in 12 patients, all of whom showed up for the first three sessions that were conducted with prenatal care visits at the obstetrics clinic. Overall, half of all sessions needed to be rescheduled in order for 78% of the sessions to be completed, she reported. One woman stopped therapy; three completed the eight sessions; and eight patients are still in therapy.

The 11 patients who completed or who continue therapy have benefited from treatment, Dr. Flynn said, and they report high satisfaction with the program. “The more flexible we are, the more likely that we're going to retain these women in therapy,” she said.

Several previous studies found that approximately 75% of women with depression during pregnancy or the postpartum period go undiagnosed or untreated, Dr. Flynn said. One of the main barriers seems to be difficulty in accessing treatment. “The treatments are probably fine. It's just that women are not accessing them,” she said. “They may or may not be ambivalent about treatment. It's just that they have chaotic lives.”

Most of the women in her pilot studies had incomes below the poverty line, and a few were homeless. Many lacked transportation. “We need to be as flexible as possible to accommodate these women,” she said.

PHOENIX — Flexibility in scheduling would help depressed women access cognitive-behavioral therapy during or just after pregnancy, a survey of 24 women found. A little more respect would be nice too, respondents said.

Results of the qualitative survey informed a revision of a cognitive-behavioral treatment manual that will be tested in a randomized, controlled trial with 60 women comparing the revised therapy model with treatment as usual, Heather A. Flynn, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

She and her associates used the Edinburgh Postnatal Depression Scale to screen 274 pregnant or postpartum women in the waiting rooms of five obstetrics clinics. The Structured Clinical Interview for DSM Disorders identified 24 of these women, who completed a questionnaire about their preferences for receiving cognitive-behavioral therapy, with major depressive disorder or minor depression. The women said they would prefer to get CBT in an obstetrician's office or at home by telephone. Postpartum women said that having child care available at the clinic would be a big help. “We're actually doing that now,” said Dr. Flynn, an assistant professor of psychiatry at the University of Michigan, Ann Arbor.

All 24 women spontaneously reported that they have felt judged, disrespected, or stigmatized by health care workers. “Women did not feel that they were listened to” as they tried to get help, she said.

The women did not acknowledge that what they were experiencing was depression, however, and did not want therapy to be presented as treatment for depression. “The way you present treatment is very important,” Dr. Flynn suggested.

The investigators preliminarily tested an eight-session program of CBT in 12 patients, all of whom showed up for the first three sessions that were conducted with prenatal care visits at the obstetrics clinic. Overall, half of all sessions needed to be rescheduled in order for 78% of the sessions to be completed, she reported. One woman stopped therapy; three completed the eight sessions; and eight patients are still in therapy.

The 11 patients who completed or who continue therapy have benefited from treatment, Dr. Flynn said, and they report high satisfaction with the program. “The more flexible we are, the more likely that we're going to retain these women in therapy,” she said.

Several previous studies found that approximately 75% of women with depression during pregnancy or the postpartum period go undiagnosed or untreated, Dr. Flynn said. One of the main barriers seems to be difficulty in accessing treatment. “The treatments are probably fine. It's just that women are not accessing them,” she said. “They may or may not be ambivalent about treatment. It's just that they have chaotic lives.”

Most of the women in her pilot studies had incomes below the poverty line, and a few were homeless. Many lacked transportation. “We need to be as flexible as possible to accommodate these women,” she said.

PHOENIX — Flexibility in scheduling would help depressed women access cognitive-behavioral therapy during or just after pregnancy, a survey of 24 women found. A little more respect would be nice too, respondents said.

Results of the qualitative survey informed a revision of a cognitive-behavioral treatment manual that will be tested in a randomized, controlled trial with 60 women comparing the revised therapy model with treatment as usual, Heather A. Flynn, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

She and her associates used the Edinburgh Postnatal Depression Scale to screen 274 pregnant or postpartum women in the waiting rooms of five obstetrics clinics. The Structured Clinical Interview for DSM Disorders identified 24 of these women, who completed a questionnaire about their preferences for receiving cognitive-behavioral therapy, with major depressive disorder or minor depression. The women said they would prefer to get CBT in an obstetrician's office or at home by telephone. Postpartum women said that having child care available at the clinic would be a big help. “We're actually doing that now,” said Dr. Flynn, an assistant professor of psychiatry at the University of Michigan, Ann Arbor.

All 24 women spontaneously reported that they have felt judged, disrespected, or stigmatized by health care workers. “Women did not feel that they were listened to” as they tried to get help, she said.

The women did not acknowledge that what they were experiencing was depression, however, and did not want therapy to be presented as treatment for depression. “The way you present treatment is very important,” Dr. Flynn suggested.

The investigators preliminarily tested an eight-session program of CBT in 12 patients, all of whom showed up for the first three sessions that were conducted with prenatal care visits at the obstetrics clinic. Overall, half of all sessions needed to be rescheduled in order for 78% of the sessions to be completed, she reported. One woman stopped therapy; three completed the eight sessions; and eight patients are still in therapy.

The 11 patients who completed or who continue therapy have benefited from treatment, Dr. Flynn said, and they report high satisfaction with the program. “The more flexible we are, the more likely that we're going to retain these women in therapy,” she said.

Several previous studies found that approximately 75% of women with depression during pregnancy or the postpartum period go undiagnosed or untreated, Dr. Flynn said. One of the main barriers seems to be difficulty in accessing treatment. “The treatments are probably fine. It's just that women are not accessing them,” she said. “They may or may not be ambivalent about treatment. It's just that they have chaotic lives.”

Most of the women in her pilot studies had incomes below the poverty line, and a few were homeless. Many lacked transportation. “We need to be as flexible as possible to accommodate these women,” she said.

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 patients who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease.

As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

The results emphasize that all patients with interstitial lung disease should be evaluated by a rheumatologist, concluded Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, she said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previously published studies suggest.

For example, nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate, recently published study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose the condition as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review conducted by a group of pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data.

The physicians also reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians.

They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues suggestive of a rheumatologic diagnosis.

Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and also undifferentiated connective tissue disease.

The patient cohort was half female, with a median age of 63 years and a history of smoking in 23 (82%) of patients.

The multidisciplinary interstitial lung disease clinic now meets weekly and has evaluated an additional 28 patients.

In this group, diagnoses were changed in eight patients, including five patients referred for idiopathic disease who were ultimately found to have rheumatic disease-related interstitial lung disease, Dr. Castelino commented.

The investigators reported having no potential conflicts of interest related to this study.

Rheumatologists' recognition of rheumatic lung disease changed therapy in 50% of cases. DR. CASTELINO

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 patients who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease.

As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

The results emphasize that all patients with interstitial lung disease should be evaluated by a rheumatologist, concluded Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, she said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previously published studies suggest.

For example, nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate, recently published study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose the condition as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review conducted by a group of pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data.

The physicians also reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians.

They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues suggestive of a rheumatologic diagnosis.

Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and also undifferentiated connective tissue disease.

The patient cohort was half female, with a median age of 63 years and a history of smoking in 23 (82%) of patients.

The multidisciplinary interstitial lung disease clinic now meets weekly and has evaluated an additional 28 patients.

In this group, diagnoses were changed in eight patients, including five patients referred for idiopathic disease who were ultimately found to have rheumatic disease-related interstitial lung disease, Dr. Castelino commented.

The investigators reported having no potential conflicts of interest related to this study.

Rheumatologists' recognition of rheumatic lung disease changed therapy in 50% of cases. DR. CASTELINO

SAN FRANCISCO — Clinicians detected underlying rheumatic disease in 17 of 28 patients referred to a multidisciplinary clinic for interstitial lung disease.

The evaluations changed the diagnosis in 11 of the 28 patients, including 4 of 15 patients who had been referred for idiopathic interstitial lung disease and 7 of 13 who had been referred for rheumatic disease related to interstitial lung disease.

As a result, clinicians changed therapy for 14 (50%) of the patients, Dr. Flavia V. Castelino and her associates reported at the annual meeting of the American College of Rheumatology.

The results emphasize that all patients with interstitial lung disease should be evaluated by a rheumatologist, concluded Dr. Castelino of Massachusetts General Hospital, Boston.

Distinguishing between interstitial lung disease that is idiopathic versus related to rheumatic disease is important because the former carries a worse prognosis, and the response to treatment may differ, she said.

A separate retrospective study of 362 cases of interstitial lung disease found 5-year survival rates of approximately 40% with idiopathic disease and approximately 70% with cases that were associated with rheumatic disease (Am. J. Resp. Crit. Care Med. 2007;175:705–11).

The difference in prognosis is thought to be related to the major lung histopathology, previously published studies suggest.

For example, nonspecific interstitial pneumonia was present in 4 (9%) of 47 patients with idiopathic interstitial lung disease and in 23 (83%) of 28 patients with undifferentiated connective tissue disease and interstitial lung disease in one study (Am. J. Resp. Crit. Care Med. 2007;176:691–7).

A separate, recently published study of 39 cases of interstitial lung disease found that community physicians were more likely to diagnose the condition as idiopathic disease, compared with retrospective diagnoses from a multidisciplinary academic team review conducted by a group of pulmonologists, radiologists, and pathologists (Am. J. Resp. Crit. Care Med. 2007;175:1054–60).

In the current prospective study of patients referred by pulmonologists over an 8-month period to a new multidisciplinary clinic at Brigham and Women's Hospital, Boston, all patients were evaluated by a pulmonologist and a rheumatologist, who took a complete history and physical examination (including capillary microscopy) and reviewed laboratory and serologic data.

The physicians also reviewed available imaging and pathologic specimens in consultation with a dedicated radiologist and a pathologist experienced in interstitial lung disease.

Additional serologic tests, imaging, or biopsies were performed at the discretion of the clinic physicians.

They initiated or changed therapy in collaboration with the referring physician.

Evaluations by a rheumatologist significantly affected diagnoses because of additional serologic testing (such as a myositis panel) and because the rheumatologist was able to elicit subtle clues suggestive of a rheumatologic diagnosis.

Recognition of “mechanic's hands,” periungual erythema, abnormal capillary microscopy and inflammatory arthritis led to new diagnoses including antisynthetase syndrome, systemic sclerosis, rheumatoid arthritis-associated interstitial lung disease, mixed connective tissue disease, dermatomyositis, and also undifferentiated connective tissue disease.

The patient cohort was half female, with a median age of 63 years and a history of smoking in 23 (82%) of patients.

The multidisciplinary interstitial lung disease clinic now meets weekly and has evaluated an additional 28 patients.

In this group, diagnoses were changed in eight patients, including five patients referred for idiopathic disease who were ultimately found to have rheumatic disease-related interstitial lung disease, Dr. Castelino commented.

The investigators reported having no potential conflicts of interest related to this study.

Rheumatologists' recognition of rheumatic lung disease changed therapy in 50% of cases. DR. CASTELINO