Sherry Boschert

SAN FRANCISCO — The physiological lag between glucose levels in the blood and in interstitial fluid can wreak havoc in continuous glucose monitoring if the lag isn't considered when calibrating the monitors, according to Dr. Howard A. Wolpert.

Patients with diabetes who want to use continuous glucose monitors need to be instructed to calibrate the devices when their glucose levels are in a steady state rather than during a period of changing glucose levels, Dr. Wolpert said at a meeting sponsored by the American Diabetes Association.

Finger-stick monitors and the electrochemical sensors in continuous glucose monitors (CGMs) work on the same principle, based on glucose oxidase breaking down glucose and generating electrons, which are measured by the monitor's sensors. Finger-stick monitors measure serum glucose, and continuous monitors measure glucose in the interstitial fluid. When glucose levels are changing—such as rising glucose levels seen particularly after meals—there can be as much as a 30-minute delay before a changed glucose level in blood is reflected in interstitial fluid.

“If patients calibrate the continuous glucose monitoring devices when their glucose is changing and they're not in steady state, their sensor is going to be calibrated inaccurately and not give them reliable readings,” said Dr. Wolpert of the Joslin Diabetes Center, Boston.

This has implications not only for accuracy but also for the patient's confidence in the device and willingness to monitor glucose levels. It also can affect the choices the patient makes when recovering from a hypoglycemic episode, and when setting the monitor's alarms at optimal levels, he said.

Dr. Wolpert gave the example of a person's blood glucose increasing 3 mg/dL per minute, which is not uncommon after a meal. If that patient has a 10-minute physiological lag, there's a 30-mg/dL discrepancy between the blood glucose and interstitial fluid glucose. By calibrating a continuous glucose monitor at that time, the patient might tell the monitor that the 140 mg/dL that it's measuring in the interstitial fluid should be 170 mg/dL instead, which would be inaccurate. That throws off future readings.

“It's something that patients need to be aware of—otherwise, they'll lose confidence in the technology. They'll think it's an inaccurate device rather than just a biologic lag,” he said.

Data from a study of one model of continuous glucose monitor show that when it was calibrated as glucose levels were rapidly changing—either increasing or decreasing by more than 2 mg/dL per minute—only 50%-60% of its readings were in the clinically accurate Clarke error grid A zone, with a mean absolute relative difference of around 17%, Dr. Wolpert said. When the monitor was calibrated while glucose was relatively stable, accuracy improved, with up to 85% of readings in the A zone and a mean absolute relative difference of 9%.

In addition, when glucose is changing rapidly, the physiological lag results in the monitor not fully registering the rate of change, which can mislead the patient. Patients recovering from hypoglycemia may think they need more carbohydrates because the monitor reading is 55 mg/dL although the plasma glucose has come up to normal, above 70 mg/dL. These patients should do a finger-stick measurement before deciding whether to take any more carbohydrates, Dr. Wolpert said.

The lag also has implications for sensor alarm settings. One patient who had set his continuous glucose monitor alarms to alert him when glucose levels hit a high of 200 mg/dL or a low of 60 mg/dL was awakened by a high alarm at night. A finger-stick test showed a glucose level of 238 mg/dL. He gave himself a bolus of insulin and went back to sleep. In the morning, his finger-stick glucose measurement was 52 mg/dL, but the continuous glucose monitor hadn't warned him with a low alarm because it still read a level of 70 mg/dL. “This is a reflection of the lag,” Dr. Wolpert said.

He recommended that the patient increase the low alarm to a higher level of 70–75 mg/dL. The patient tried that but complained of too many false alarms, and reverted to the former settings. Dr. Wolpert noted that wider settings for alarm levels will reduce the number of irritating and intrusive false alarms, but patients won't know of all their high and low glucose levels.

The narrower alarm settings may be best for patients with severe hypoglycemia or frequent hypoglycemic reactions, to be sure they're alerted of those situations, he suggested. Wider alarm settings may be best for patients new to continuous glucose monitors, “until they really get a handle on their glucose fluctuations,” he said. “As they improve their control, tighten up those thresholds.”

Dr. Wolpert has relationships with several companies that make continuous glucose monitors and other monitoring equipment, including Medtronic Inc., Lifescan Inc., Roche Diagnostics, and Novo Nordisk.

SAN FRANCISCO — The physiological lag between glucose levels in the blood and in interstitial fluid can wreak havoc in continuous glucose monitoring if the lag isn't considered when calibrating the monitors, according to Dr. Howard A. Wolpert.

Patients with diabetes who want to use continuous glucose monitors need to be instructed to calibrate the devices when their glucose levels are in a steady state rather than during a period of changing glucose levels, Dr. Wolpert said at a meeting sponsored by the American Diabetes Association.

Finger-stick monitors and the electrochemical sensors in continuous glucose monitors (CGMs) work on the same principle, based on glucose oxidase breaking down glucose and generating electrons, which are measured by the monitor's sensors. Finger-stick monitors measure serum glucose, and continuous monitors measure glucose in the interstitial fluid. When glucose levels are changing—such as rising glucose levels seen particularly after meals—there can be as much as a 30-minute delay before a changed glucose level in blood is reflected in interstitial fluid.

“If patients calibrate the continuous glucose monitoring devices when their glucose is changing and they're not in steady state, their sensor is going to be calibrated inaccurately and not give them reliable readings,” said Dr. Wolpert of the Joslin Diabetes Center, Boston.

This has implications not only for accuracy but also for the patient's confidence in the device and willingness to monitor glucose levels. It also can affect the choices the patient makes when recovering from a hypoglycemic episode, and when setting the monitor's alarms at optimal levels, he said.

Dr. Wolpert gave the example of a person's blood glucose increasing 3 mg/dL per minute, which is not uncommon after a meal. If that patient has a 10-minute physiological lag, there's a 30-mg/dL discrepancy between the blood glucose and interstitial fluid glucose. By calibrating a continuous glucose monitor at that time, the patient might tell the monitor that the 140 mg/dL that it's measuring in the interstitial fluid should be 170 mg/dL instead, which would be inaccurate. That throws off future readings.

“It's something that patients need to be aware of—otherwise, they'll lose confidence in the technology. They'll think it's an inaccurate device rather than just a biologic lag,” he said.

Data from a study of one model of continuous glucose monitor show that when it was calibrated as glucose levels were rapidly changing—either increasing or decreasing by more than 2 mg/dL per minute—only 50%-60% of its readings were in the clinically accurate Clarke error grid A zone, with a mean absolute relative difference of around 17%, Dr. Wolpert said. When the monitor was calibrated while glucose was relatively stable, accuracy improved, with up to 85% of readings in the A zone and a mean absolute relative difference of 9%.

In addition, when glucose is changing rapidly, the physiological lag results in the monitor not fully registering the rate of change, which can mislead the patient. Patients recovering from hypoglycemia may think they need more carbohydrates because the monitor reading is 55 mg/dL although the plasma glucose has come up to normal, above 70 mg/dL. These patients should do a finger-stick measurement before deciding whether to take any more carbohydrates, Dr. Wolpert said.

The lag also has implications for sensor alarm settings. One patient who had set his continuous glucose monitor alarms to alert him when glucose levels hit a high of 200 mg/dL or a low of 60 mg/dL was awakened by a high alarm at night. A finger-stick test showed a glucose level of 238 mg/dL. He gave himself a bolus of insulin and went back to sleep. In the morning, his finger-stick glucose measurement was 52 mg/dL, but the continuous glucose monitor hadn't warned him with a low alarm because it still read a level of 70 mg/dL. “This is a reflection of the lag,” Dr. Wolpert said.

He recommended that the patient increase the low alarm to a higher level of 70–75 mg/dL. The patient tried that but complained of too many false alarms, and reverted to the former settings. Dr. Wolpert noted that wider settings for alarm levels will reduce the number of irritating and intrusive false alarms, but patients won't know of all their high and low glucose levels.

The narrower alarm settings may be best for patients with severe hypoglycemia or frequent hypoglycemic reactions, to be sure they're alerted of those situations, he suggested. Wider alarm settings may be best for patients new to continuous glucose monitors, “until they really get a handle on their glucose fluctuations,” he said. “As they improve their control, tighten up those thresholds.”

Dr. Wolpert has relationships with several companies that make continuous glucose monitors and other monitoring equipment, including Medtronic Inc., Lifescan Inc., Roche Diagnostics, and Novo Nordisk.

SAN FRANCISCO — The physiological lag between glucose levels in the blood and in interstitial fluid can wreak havoc in continuous glucose monitoring if the lag isn't considered when calibrating the monitors, according to Dr. Howard A. Wolpert.

Patients with diabetes who want to use continuous glucose monitors need to be instructed to calibrate the devices when their glucose levels are in a steady state rather than during a period of changing glucose levels, Dr. Wolpert said at a meeting sponsored by the American Diabetes Association.

Finger-stick monitors and the electrochemical sensors in continuous glucose monitors (CGMs) work on the same principle, based on glucose oxidase breaking down glucose and generating electrons, which are measured by the monitor's sensors. Finger-stick monitors measure serum glucose, and continuous monitors measure glucose in the interstitial fluid. When glucose levels are changing—such as rising glucose levels seen particularly after meals—there can be as much as a 30-minute delay before a changed glucose level in blood is reflected in interstitial fluid.

“If patients calibrate the continuous glucose monitoring devices when their glucose is changing and they're not in steady state, their sensor is going to be calibrated inaccurately and not give them reliable readings,” said Dr. Wolpert of the Joslin Diabetes Center, Boston.

This has implications not only for accuracy but also for the patient's confidence in the device and willingness to monitor glucose levels. It also can affect the choices the patient makes when recovering from a hypoglycemic episode, and when setting the monitor's alarms at optimal levels, he said.

Dr. Wolpert gave the example of a person's blood glucose increasing 3 mg/dL per minute, which is not uncommon after a meal. If that patient has a 10-minute physiological lag, there's a 30-mg/dL discrepancy between the blood glucose and interstitial fluid glucose. By calibrating a continuous glucose monitor at that time, the patient might tell the monitor that the 140 mg/dL that it's measuring in the interstitial fluid should be 170 mg/dL instead, which would be inaccurate. That throws off future readings.

“It's something that patients need to be aware of—otherwise, they'll lose confidence in the technology. They'll think it's an inaccurate device rather than just a biologic lag,” he said.

Data from a study of one model of continuous glucose monitor show that when it was calibrated as glucose levels were rapidly changing—either increasing or decreasing by more than 2 mg/dL per minute—only 50%-60% of its readings were in the clinically accurate Clarke error grid A zone, with a mean absolute relative difference of around 17%, Dr. Wolpert said. When the monitor was calibrated while glucose was relatively stable, accuracy improved, with up to 85% of readings in the A zone and a mean absolute relative difference of 9%.

In addition, when glucose is changing rapidly, the physiological lag results in the monitor not fully registering the rate of change, which can mislead the patient. Patients recovering from hypoglycemia may think they need more carbohydrates because the monitor reading is 55 mg/dL although the plasma glucose has come up to normal, above 70 mg/dL. These patients should do a finger-stick measurement before deciding whether to take any more carbohydrates, Dr. Wolpert said.

The lag also has implications for sensor alarm settings. One patient who had set his continuous glucose monitor alarms to alert him when glucose levels hit a high of 200 mg/dL or a low of 60 mg/dL was awakened by a high alarm at night. A finger-stick test showed a glucose level of 238 mg/dL. He gave himself a bolus of insulin and went back to sleep. In the morning, his finger-stick glucose measurement was 52 mg/dL, but the continuous glucose monitor hadn't warned him with a low alarm because it still read a level of 70 mg/dL. “This is a reflection of the lag,” Dr. Wolpert said.

He recommended that the patient increase the low alarm to a higher level of 70–75 mg/dL. The patient tried that but complained of too many false alarms, and reverted to the former settings. Dr. Wolpert noted that wider settings for alarm levels will reduce the number of irritating and intrusive false alarms, but patients won't know of all their high and low glucose levels.

The narrower alarm settings may be best for patients with severe hypoglycemia or frequent hypoglycemic reactions, to be sure they're alerted of those situations, he suggested. Wider alarm settings may be best for patients new to continuous glucose monitors, “until they really get a handle on their glucose fluctuations,” he said. “As they improve their control, tighten up those thresholds.”

Dr. Wolpert has relationships with several companies that make continuous glucose monitors and other monitoring equipment, including Medtronic Inc., Lifescan Inc., Roche Diagnostics, and Novo Nordisk.

SAN FRANCISCO — An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits—beyond improvements in the skills trained directly—from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Providers who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1–5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately.

Although many available interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions.

Many available interventions claim to improve cognition, but there is little empiric evidence of their efficacy. DR. ZELINSKI

SAN FRANCISCO — An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits—beyond improvements in the skills trained directly—from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Providers who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1–5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately.

Although many available interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions.

Many available interventions claim to improve cognition, but there is little empiric evidence of their efficacy. DR. ZELINSKI

SAN FRANCISCO — An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits—beyond improvements in the skills trained directly—from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Providers who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1–5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately.

Although many available interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions.

Many available interventions claim to improve cognition, but there is little empiric evidence of their efficacy. DR. ZELINSKI

SAN FRANCISCO — Eight weeks after giving birth, about 1 in 10 patients reported persistent delivery-related pain regardless of whether they were delivered vaginally or by cesarean section in a study of 972 U.S. women.

“Previous reports may have overestimated the incidence of persistent pain” after C-section, said Dr. Peter H. Pan, a professor of anesthesiology at Wake Forest University, Winston-Salem, N.C.

There were no significant differences in the severity of pain or its effect on daily activities between the 668 women who delivered vaginally and the 304 who underwent C-section in this multicenter prospective study, he said at the annual meeting of the American Society of Anesthesiologists.

In the vaginal delivery group, 10% reported delivery-related pain at 8 weeks post partum, and 49% of these said the pain affected their daily activities. In the C-section group, 9% had persistent pain 8 weeks after delivery, and 45% of these said it affected their daily activities, reported Dr. Pan and his associates.

Previous studies of persistent pain after delivery either were retrospective or included only small cohorts of women outside the United States. Investigators in one study reported persistent perineal pain 6–24 weeks after vaginal delivery in 4%–7% of women. Researchers in a separate study reported that 18% of women had persistent pain at 3 months post partum and 12% had pain after 10 months.

The current study enrolled women while they were in the hospital for delivery and had them complete a questionnaire and interview to assess preexisting pain syndromes, psychological factors, and sensory perception and sensitivity. The patients were contacted telephonically 8 weeks later to assess the presence of pain related to delivery, its severity and location, its impact on daily living, and the presence of clinical depression. Women reporting delivery-related pain at 8 weeks post partum are being reinterviewed at 6 and 12 months post partum.

Women with third-degree perineal tears or episiotomies were more likely to report persistent pain, but this was not true of women with less severe lacerations, Dr. Pan said. There was no significant difference between primary or repeat C-sections as predictors for persistent pain, statistical analysis suggested.

SAN FRANCISCO — Eight weeks after giving birth, about 1 in 10 patients reported persistent delivery-related pain regardless of whether they were delivered vaginally or by cesarean section in a study of 972 U.S. women.

“Previous reports may have overestimated the incidence of persistent pain” after C-section, said Dr. Peter H. Pan, a professor of anesthesiology at Wake Forest University, Winston-Salem, N.C.

There were no significant differences in the severity of pain or its effect on daily activities between the 668 women who delivered vaginally and the 304 who underwent C-section in this multicenter prospective study, he said at the annual meeting of the American Society of Anesthesiologists.

In the vaginal delivery group, 10% reported delivery-related pain at 8 weeks post partum, and 49% of these said the pain affected their daily activities. In the C-section group, 9% had persistent pain 8 weeks after delivery, and 45% of these said it affected their daily activities, reported Dr. Pan and his associates.

Previous studies of persistent pain after delivery either were retrospective or included only small cohorts of women outside the United States. Investigators in one study reported persistent perineal pain 6–24 weeks after vaginal delivery in 4%–7% of women. Researchers in a separate study reported that 18% of women had persistent pain at 3 months post partum and 12% had pain after 10 months.

The current study enrolled women while they were in the hospital for delivery and had them complete a questionnaire and interview to assess preexisting pain syndromes, psychological factors, and sensory perception and sensitivity. The patients were contacted telephonically 8 weeks later to assess the presence of pain related to delivery, its severity and location, its impact on daily living, and the presence of clinical depression. Women reporting delivery-related pain at 8 weeks post partum are being reinterviewed at 6 and 12 months post partum.

Women with third-degree perineal tears or episiotomies were more likely to report persistent pain, but this was not true of women with less severe lacerations, Dr. Pan said. There was no significant difference between primary or repeat C-sections as predictors for persistent pain, statistical analysis suggested.

SAN FRANCISCO — Eight weeks after giving birth, about 1 in 10 patients reported persistent delivery-related pain regardless of whether they were delivered vaginally or by cesarean section in a study of 972 U.S. women.

“Previous reports may have overestimated the incidence of persistent pain” after C-section, said Dr. Peter H. Pan, a professor of anesthesiology at Wake Forest University, Winston-Salem, N.C.

There were no significant differences in the severity of pain or its effect on daily activities between the 668 women who delivered vaginally and the 304 who underwent C-section in this multicenter prospective study, he said at the annual meeting of the American Society of Anesthesiologists.

In the vaginal delivery group, 10% reported delivery-related pain at 8 weeks post partum, and 49% of these said the pain affected their daily activities. In the C-section group, 9% had persistent pain 8 weeks after delivery, and 45% of these said it affected their daily activities, reported Dr. Pan and his associates.

Previous studies of persistent pain after delivery either were retrospective or included only small cohorts of women outside the United States. Investigators in one study reported persistent perineal pain 6–24 weeks after vaginal delivery in 4%–7% of women. Researchers in a separate study reported that 18% of women had persistent pain at 3 months post partum and 12% had pain after 10 months.

The current study enrolled women while they were in the hospital for delivery and had them complete a questionnaire and interview to assess preexisting pain syndromes, psychological factors, and sensory perception and sensitivity. The patients were contacted telephonically 8 weeks later to assess the presence of pain related to delivery, its severity and location, its impact on daily living, and the presence of clinical depression. Women reporting delivery-related pain at 8 weeks post partum are being reinterviewed at 6 and 12 months post partum.

Women with third-degree perineal tears or episiotomies were more likely to report persistent pain, but this was not true of women with less severe lacerations, Dr. Pan said. There was no significant difference between primary or repeat C-sections as predictors for persistent pain, statistical analysis suggested.

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intra- and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep.”

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make “the whole surgery and anesthesia a little more unpleasant,” Dr. Allen said. The study's results have affected practice at his institution.

“We're certainly more vigilant about asking about intraoperative nausea and vomiting, and we treat it a bit more aggressively” in women undergoing C-section using neuraxial anesthesia. “We may not all use 5-HT₃ receptor antagonists, but we administer some sort of pharmacologic agent.”

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intra- and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep.”

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make “the whole surgery and anesthesia a little more unpleasant,” Dr. Allen said. The study's results have affected practice at his institution.

“We're certainly more vigilant about asking about intraoperative nausea and vomiting, and we treat it a bit more aggressively” in women undergoing C-section using neuraxial anesthesia. “We may not all use 5-HT₃ receptor antagonists, but we administer some sort of pharmacologic agent.”

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intra- and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep.”

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make “the whole surgery and anesthesia a little more unpleasant,” Dr. Allen said. The study's results have affected practice at his institution.

“We're certainly more vigilant about asking about intraoperative nausea and vomiting, and we treat it a bit more aggressively” in women undergoing C-section using neuraxial anesthesia. “We may not all use 5-HT₃ receptor antagonists, but we administer some sort of pharmacologic agent.”

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea, compared with nonpregnant women, in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia, compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

About 2% of adult women have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. In an interview, Dr. Higgins attributed the increase in sleep apnea cases to the greater prevalence of obesity. The incidence of obstructive sleep apnea in pregnancy has been unknown.

In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, which identifies patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

The researchers found pregnancy doubled the chance for screening positive on the Berlin screen, and pregnant women screening positive on it were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those screening positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea, compared with nonpregnant women, in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia, compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

About 2% of adult women have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. In an interview, Dr. Higgins attributed the increase in sleep apnea cases to the greater prevalence of obesity. The incidence of obstructive sleep apnea in pregnancy has been unknown.

In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, which identifies patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

The researchers found pregnancy doubled the chance for screening positive on the Berlin screen, and pregnant women screening positive on it were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those screening positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea, compared with nonpregnant women, in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia, compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

About 2% of adult women have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. In an interview, Dr. Higgins attributed the increase in sleep apnea cases to the greater prevalence of obesity. The incidence of obstructive sleep apnea in pregnancy has been unknown.

In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, which identifies patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

The researchers found pregnancy doubled the chance for screening positive on the Berlin screen, and pregnant women screening positive on it were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those screening positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

SAN FRANCISCO — Vulvodynia so profoundly affects quality of life that management needs to address the physical, psychological, sexual, and relationship problems caused by the pain.

“Support, support, support” patients with vulvodynia by reassuring them that they're not crazy and validating the reality of their pain, Dr. Erika Klemperer said at a meeting sponsored by Skin Disease Education Foundation.

Refer women with vulvodynia for psychological counseling when appropriate, but be clear about why you're doing so. “It's not because we think they're crazy, but because pain makes people crazy,” often triggering depression, anxiety, or other problems, said Dr. Klemperer, a private-practice dermatologist in Santa Barbara, Calif.

Vulvodynia is a diagnosis of exclusion defined as vulvar discomfort—usually a “burning” pain—occurring without any relevant visible findings or a specific, clinically identifiable, neurologic disorder. Patients may have generalized vulvodynia or vestibulodynia. An estimated 3%–16% of women experience vulvodynia during their lifetimes.

Dr. Klemperer tells patients, “I know this pain isn't in your head. This is real, and I'm going to be here to get you through this.” Make an effort to understand clearly the patient's and her partner's goals for therapy so that you can guide them toward realistic expectations, because treatment may not cure the problem but should help control the pain. There are few randomized, controlled trials on treating vulvodynia, so therapy rests on expert opinion and few data.

Treatment starts with vulvar care measures, such as avoiding all irritants. Tell patients to wash the genital area using only their fingers and water, then pat dry (not blow dry). Bland emollients may help. For lubrication during intercourse, try olive oil to avoid the preservatives in commercial products.

First-line medication would be a topical anesthetic, especially for vestibulodynia. Other topical therapies tend to burn or are ineffective. Lidocaine 5% ointment or 2% gel may be used as needed or in twice- or thrice-daily regimens. Patients also can apply it 30 minutes before sexual activity but should wipe it off before sex so that it doesn't cause numbness in their partner. Dispense lidocaine gel in a 30-g tube and warn patients not to use more than 20 g per day to avoid side effects of erythema, edema, and purpura.

A 2003 study looked at women who placed a cotton ball coated with lidocaine 5% ointment on the vestibule and left it overnight, for at least 8 hours. About 75% of women were able to resume intercourse during the study, “which makes sense because we're trying to break that pain loop, break that feedback,” Dr. Klemperer said.

Off-label use of systemic therapies usually starts with tricyclic antidepressants, most often amitriptyline. Tricyclics improve vulvodynia by about 60% in around half of patients. Be specific in explaining to patients that you're using these medications to try to cool down nerve fibers, and that these regimens are used for other pain problems such as diabetic neuropathy or postherpetic neuralgias.

The key to systemic therapy is to start with a low dose and increase it slowly. Dr. Klemperer usually starts a tricyclic at 10 mg nightly, increasing by 5–25 mg/week to a maximum of 150 mg nightly. Amitriptyline is available in a syrup, “so you can titrate it down to a minuscule dose. The most important thing is that they tolerate it.”

Gabapentin, pregabalin, venlafaxine, and duloxetine have been used as second-line systemic therapies for vulvodynia. SSRIs have not been effective in these patients.

Chinese herbal remedies and acupuncture have benefited some of Dr. Klemperer's patients with vulvodynia, she said. She supports using complementary therapies such as hypnotherapy, meditation, and others if the patient is interested, though no clinical trials support their use. Strict dietary regimens probably are not wise in these already stressed-out patients, she added.

Injectable therapies have been tried, but the efficacy of interferon-α is questionable, so Dr. Klemperer doesn't use it. Trigger-point injections are difficult to tolerate. Pain specialists sometimes use nerve blocks for vulvodynia, and botulinum toxin has been mentioned in a few case reports.

Surgery should be reserved for patients with pure vestibulodynia with chronic, ongoing symptoms resistant to all other therapies. If vaginismus is present, treat that before sending the patient to vestibulectomy, which may alleviate symptoms in 60%–85% of cases.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Vulvodynia so profoundly affects quality of life that management needs to address the physical, psychological, sexual, and relationship problems caused by the pain.

“Support, support, support” patients with vulvodynia by reassuring them that they're not crazy and validating the reality of their pain, Dr. Erika Klemperer said at a meeting sponsored by Skin Disease Education Foundation.

Refer women with vulvodynia for psychological counseling when appropriate, but be clear about why you're doing so. “It's not because we think they're crazy, but because pain makes people crazy,” often triggering depression, anxiety, or other problems, said Dr. Klemperer, a private-practice dermatologist in Santa Barbara, Calif.

Vulvodynia is a diagnosis of exclusion defined as vulvar discomfort—usually a “burning” pain—occurring without any relevant visible findings or a specific, clinically identifiable, neurologic disorder. Patients may have generalized vulvodynia or vestibulodynia. An estimated 3%–16% of women experience vulvodynia during their lifetimes.

Dr. Klemperer tells patients, “I know this pain isn't in your head. This is real, and I'm going to be here to get you through this.” Make an effort to understand clearly the patient's and her partner's goals for therapy so that you can guide them toward realistic expectations, because treatment may not cure the problem but should help control the pain. There are few randomized, controlled trials on treating vulvodynia, so therapy rests on expert opinion and few data.

Treatment starts with vulvar care measures, such as avoiding all irritants. Tell patients to wash the genital area using only their fingers and water, then pat dry (not blow dry). Bland emollients may help. For lubrication during intercourse, try olive oil to avoid the preservatives in commercial products.

First-line medication would be a topical anesthetic, especially for vestibulodynia. Other topical therapies tend to burn or are ineffective. Lidocaine 5% ointment or 2% gel may be used as needed or in twice- or thrice-daily regimens. Patients also can apply it 30 minutes before sexual activity but should wipe it off before sex so that it doesn't cause numbness in their partner. Dispense lidocaine gel in a 30-g tube and warn patients not to use more than 20 g per day to avoid side effects of erythema, edema, and purpura.

A 2003 study looked at women who placed a cotton ball coated with lidocaine 5% ointment on the vestibule and left it overnight, for at least 8 hours. About 75% of women were able to resume intercourse during the study, “which makes sense because we're trying to break that pain loop, break that feedback,” Dr. Klemperer said.

Off-label use of systemic therapies usually starts with tricyclic antidepressants, most often amitriptyline. Tricyclics improve vulvodynia by about 60% in around half of patients. Be specific in explaining to patients that you're using these medications to try to cool down nerve fibers, and that these regimens are used for other pain problems such as diabetic neuropathy or postherpetic neuralgias.

The key to systemic therapy is to start with a low dose and increase it slowly. Dr. Klemperer usually starts a tricyclic at 10 mg nightly, increasing by 5–25 mg/week to a maximum of 150 mg nightly. Amitriptyline is available in a syrup, “so you can titrate it down to a minuscule dose. The most important thing is that they tolerate it.”

Gabapentin, pregabalin, venlafaxine, and duloxetine have been used as second-line systemic therapies for vulvodynia. SSRIs have not been effective in these patients.

Chinese herbal remedies and acupuncture have benefited some of Dr. Klemperer's patients with vulvodynia, she said. She supports using complementary therapies such as hypnotherapy, meditation, and others if the patient is interested, though no clinical trials support their use. Strict dietary regimens probably are not wise in these already stressed-out patients, she added.

Injectable therapies have been tried, but the efficacy of interferon-α is questionable, so Dr. Klemperer doesn't use it. Trigger-point injections are difficult to tolerate. Pain specialists sometimes use nerve blocks for vulvodynia, and botulinum toxin has been mentioned in a few case reports.

Surgery should be reserved for patients with pure vestibulodynia with chronic, ongoing symptoms resistant to all other therapies. If vaginismus is present, treat that before sending the patient to vestibulectomy, which may alleviate symptoms in 60%–85% of cases.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Vulvodynia so profoundly affects quality of life that management needs to address the physical, psychological, sexual, and relationship problems caused by the pain.

“Support, support, support” patients with vulvodynia by reassuring them that they're not crazy and validating the reality of their pain, Dr. Erika Klemperer said at a meeting sponsored by Skin Disease Education Foundation.

Refer women with vulvodynia for psychological counseling when appropriate, but be clear about why you're doing so. “It's not because we think they're crazy, but because pain makes people crazy,” often triggering depression, anxiety, or other problems, said Dr. Klemperer, a private-practice dermatologist in Santa Barbara, Calif.

Vulvodynia is a diagnosis of exclusion defined as vulvar discomfort—usually a “burning” pain—occurring without any relevant visible findings or a specific, clinically identifiable, neurologic disorder. Patients may have generalized vulvodynia or vestibulodynia. An estimated 3%–16% of women experience vulvodynia during their lifetimes.

Dr. Klemperer tells patients, “I know this pain isn't in your head. This is real, and I'm going to be here to get you through this.” Make an effort to understand clearly the patient's and her partner's goals for therapy so that you can guide them toward realistic expectations, because treatment may not cure the problem but should help control the pain. There are few randomized, controlled trials on treating vulvodynia, so therapy rests on expert opinion and few data.

Treatment starts with vulvar care measures, such as avoiding all irritants. Tell patients to wash the genital area using only their fingers and water, then pat dry (not blow dry). Bland emollients may help. For lubrication during intercourse, try olive oil to avoid the preservatives in commercial products.

First-line medication would be a topical anesthetic, especially for vestibulodynia. Other topical therapies tend to burn or are ineffective. Lidocaine 5% ointment or 2% gel may be used as needed or in twice- or thrice-daily regimens. Patients also can apply it 30 minutes before sexual activity but should wipe it off before sex so that it doesn't cause numbness in their partner. Dispense lidocaine gel in a 30-g tube and warn patients not to use more than 20 g per day to avoid side effects of erythema, edema, and purpura.

A 2003 study looked at women who placed a cotton ball coated with lidocaine 5% ointment on the vestibule and left it overnight, for at least 8 hours. About 75% of women were able to resume intercourse during the study, “which makes sense because we're trying to break that pain loop, break that feedback,” Dr. Klemperer said.

Off-label use of systemic therapies usually starts with tricyclic antidepressants, most often amitriptyline. Tricyclics improve vulvodynia by about 60% in around half of patients. Be specific in explaining to patients that you're using these medications to try to cool down nerve fibers, and that these regimens are used for other pain problems such as diabetic neuropathy or postherpetic neuralgias.

The key to systemic therapy is to start with a low dose and increase it slowly. Dr. Klemperer usually starts a tricyclic at 10 mg nightly, increasing by 5–25 mg/week to a maximum of 150 mg nightly. Amitriptyline is available in a syrup, “so you can titrate it down to a minuscule dose. The most important thing is that they tolerate it.”

Gabapentin, pregabalin, venlafaxine, and duloxetine have been used as second-line systemic therapies for vulvodynia. SSRIs have not been effective in these patients.

Chinese herbal remedies and acupuncture have benefited some of Dr. Klemperer's patients with vulvodynia, she said. She supports using complementary therapies such as hypnotherapy, meditation, and others if the patient is interested, though no clinical trials support their use. Strict dietary regimens probably are not wise in these already stressed-out patients, she added.

Injectable therapies have been tried, but the efficacy of interferon-α is questionable, so Dr. Klemperer doesn't use it. Trigger-point injections are difficult to tolerate. Pain specialists sometimes use nerve blocks for vulvodynia, and botulinum toxin has been mentioned in a few case reports.

Surgery should be reserved for patients with pure vestibulodynia with chronic, ongoing symptoms resistant to all other therapies. If vaginismus is present, treat that before sending the patient to vestibulectomy, which may alleviate symptoms in 60%–85% of cases.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

LOS ANGELES – Significant numbers of patients with acne have debilitating symptoms normally associated with body dysmorphic disorder, Dr. Whitney P. Bowe said at the annual meeting of the Society for Investigational Dermatology.

In her screening study, 14%–21% of the 128 patients met objective and subjective criteria for a diagnosis of body dysmorphic disorder. The range varied depending on the definition of acne severity.

Body dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance, causes significant disruption in daily functioning. In the general population, 0.7%–3.0% of people are thought to have body dysmorphic disorder, which usually begins in adolescence. The preoccupation typically leads to behaviors such as skin picking and mirror checking.

Patients with body dysmorphic disorder are among the toughest patients to treat, said Dr. Bowe, who conducted the study with associates at the University of Pennsylvania, Philadelphia, while she was a medical student there. She is now an intern at Albert Einstein College of Medicine, New York. Patients with body dysmorphic disorder commonly respond poorly to treatments that do not include psychiatric medications, she explained. They are at increased risk for suicide and are more likely to threaten health care providers both legally and physically, previous reports suggest.

In the current study, the investigators categorized physician assessments of acne severity as clinically significant (which automatically precluded a diagnosis of body dysmorphic disorder) or as clinically insignificant using a stringent or less stringent set of criteria. All patients completed the Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV), which has 100% sensitivity and 92% specificity in surgical settings for detecting preoccupation with defects and at least moderate distress or impairment in functioning.

Only patients with clinically insignificant acne and a positive BDDQ-DV were considered to have body dysmorphic disorder, Dr. Bowe noted.

A total of 49 patients met stringent objective criteria for “minimal or nonexistent acne” (defined as zero or only a few scattered comedones or papules, five or fewer postinflammatory macules, and no scars). Of these, 18 scored positive on the BDDQ-DV, suggesting that 18 (14%) of all 128 patients had the disorder under the stringent criteria.

Using less stringent objective criteria that allowed up to 25% of facial involvement with small papules and comedones, 82 patients were deemed to have “mild acne,” and 27 of these scored positive on the BDDQ-DV. With the less stringent criteria, 27 (21%) of all patients had body dysmorphic disorder.

On the other end of the severity spectrum, among 11 patients who presented with nearly full facial involvement with highly inflammatory lesions and thus were disqualified from a diagnosis of body dysmorphic disorder, nearly half reported levels of preoccupation, distress, and impairment that were commensurate with patients suffering from the disorder. The investigators wondered whether acne patients who screened positive for body dysmorphic disorder are similar to other patients with the disorder, with higher rates of suicide or likelihood to threaten their physicians.

“I don't think so,” Dr. Bowe said. “I think that's a great question that we should look into.”

In particular, patients who have had severe acne that cleared suddenly with treatment like tretinoin can “vividly recall their lives with severe acne, and upon the appearance of even a few papules, are really frightened,” she said. “Are these patients the same as your typical patients with body dysmorphic disorder who have never experienced a severe physical defect that might indeed recur?”

Patients were aged 16–35 years. They were recruited from a general dermatology clinic and a specialty acne clinic at the university, and from a cosmetic outpatient practice in the community.

“Keep in mind that the BDDQ-DV is really meant to be a screening tool, and should not be used in place of a thorough psychiatric examination to ultimately make the diagnosis of body dysmorphic disorder,” Dr. Bowe said.

The BDDQ-DV should not be used in place of a thorough psychiatric examination. DR. BOWE

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

SAN FRANCISCO – Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients, reported Michael V. Vitiello, Ph.D.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, Dr. Vitiello and his associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in the control group. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes before therapy to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (with a higher score indicating less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as measured by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive CBT for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

CBT for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said.

The intervention consisted of a fairly standard series of behavioral manipulations, such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom,” Dr. Vitiello said.

The study was limited by its small size and the lack of 1-year follow-up in the control group, among other factors, he said.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use, Dr. Rollin M. Wright and her colleagues reported.

“The fact of the matter is that many older adults are on combinations of CNS medications,” said Dr. Wright of the University of Pittsburgh. In some patients, physicians may want to consider adjusting individual drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, she suggested at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70–79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study.

The investigators gathered information about medication use from containers brought in by participants and assessed cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not associated with new-onset cognitive impairment (defined as a 3MS score below 80) but was associated with new development of cognitive decline (defined as a decrease of 5 or more points on the 3MS), said Dr. Wright and her associates. She has no association with companies that make the medications being used by patients in the study, which was partially funded by the National Institute on Aging.

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications, she said.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. To measure the cumulative CNS-medication dose, the investigators divided a participant's daily dose for an individual medication by the minimum effective geriatric daily dose to calculate a standardized daily dose (SDD) and then added up the SDDs for each person. Those using the highest cumulative dose of more than three SDDs had an 82% increased risk of cognitive decline, compared with nonusers of the medications.

CNS-active drug use increased from 14% of participants at baseline to 15% of 2,284 participants at year 3, with 3% of the cohort at year 3 using the highest doses and 11% reporting long-term use. Between baseline and year 3, 20% showed cognitive decline.

At year 5, 17% of 1,907 participants evaluated were using CNS-active medications, again with 3% on the highest doses and 11% reporting long-term use. After excluding participants who showed cognitive decline at year 3, 14% of participants at year 5 showed new cognitive decline, Dr. Wright and her associates reported.

The researchers plan further studies to try to identify thresholds between benefits and risks of medication use, and to look at interventions that might help balance the benefits and risks when making decisions about medication dosing.

Indications for CNS-active medication use in the study included sleep problems in 11%, anxiety in 34%, osteoarthritis in 15%, cancer in 18%, depression in 4%, and moderate or worse bodily pain in 40%.

The study cohort was 53% female and 37% black, with a mean age of 74 years.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use, Dr. Rollin M. Wright and her colleagues reported.

“The fact of the matter is that many older adults are on combinations of CNS medications,” said Dr. Wright of the University of Pittsburgh. In some patients, physicians may want to consider adjusting individual drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, she suggested at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70–79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study.

The investigators gathered information about medication use from containers brought in by participants and assessed cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not associated with new-onset cognitive impairment (defined as a 3MS score below 80) but was associated with new development of cognitive decline (defined as a decrease of 5 or more points on the 3MS), said Dr. Wright and her associates. She has no association with companies that make the medications being used by patients in the study, which was partially funded by the National Institute on Aging.

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications, she said.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. To measure the cumulative CNS-medication dose, the investigators divided a participant's daily dose for an individual medication by the minimum effective geriatric daily dose to calculate a standardized daily dose (SDD) and then added up the SDDs for each person. Those using the highest cumulative dose of more than three SDDs had an 82% increased risk of cognitive decline, compared with nonusers of the medications.

CNS-active drug use increased from 14% of participants at baseline to 15% of 2,284 participants at year 3, with 3% of the cohort at year 3 using the highest doses and 11% reporting long-term use. Between baseline and year 3, 20% showed cognitive decline.

At year 5, 17% of 1,907 participants evaluated were using CNS-active medications, again with 3% on the highest doses and 11% reporting long-term use. After excluding participants who showed cognitive decline at year 3, 14% of participants at year 5 showed new cognitive decline, Dr. Wright and her associates reported.

The researchers plan further studies to try to identify thresholds between benefits and risks of medication use, and to look at interventions that might help balance the benefits and risks when making decisions about medication dosing.

Indications for CNS-active medication use in the study included sleep problems in 11%, anxiety in 34%, osteoarthritis in 15%, cancer in 18%, depression in 4%, and moderate or worse bodily pain in 40%.

The study cohort was 53% female and 37% black, with a mean age of 74 years.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use, Dr. Rollin M. Wright and her colleagues reported.

“The fact of the matter is that many older adults are on combinations of CNS medications,” said Dr. Wright of the University of Pittsburgh. In some patients, physicians may want to consider adjusting individual drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, she suggested at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70–79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study.

The investigators gathered information about medication use from containers brought in by participants and assessed cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not associated with new-onset cognitive impairment (defined as a 3MS score below 80) but was associated with new development of cognitive decline (defined as a decrease of 5 or more points on the 3MS), said Dr. Wright and her associates. She has no association with companies that make the medications being used by patients in the study, which was partially funded by the National Institute on Aging.

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications, she said.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. To measure the cumulative CNS-medication dose, the investigators divided a participant's daily dose for an individual medication by the minimum effective geriatric daily dose to calculate a standardized daily dose (SDD) and then added up the SDDs for each person. Those using the highest cumulative dose of more than three SDDs had an 82% increased risk of cognitive decline, compared with nonusers of the medications.

CNS-active drug use increased from 14% of participants at baseline to 15% of 2,284 participants at year 3, with 3% of the cohort at year 3 using the highest doses and 11% reporting long-term use. Between baseline and year 3, 20% showed cognitive decline.

At year 5, 17% of 1,907 participants evaluated were using CNS-active medications, again with 3% on the highest doses and 11% reporting long-term use. After excluding participants who showed cognitive decline at year 3, 14% of participants at year 5 showed new cognitive decline, Dr. Wright and her associates reported.

The researchers plan further studies to try to identify thresholds between benefits and risks of medication use, and to look at interventions that might help balance the benefits and risks when making decisions about medication dosing.

Indications for CNS-active medication use in the study included sleep problems in 11%, anxiety in 34%, osteoarthritis in 15%, cancer in 18%, depression in 4%, and moderate or worse bodily pain in 40%.

The study cohort was 53% female and 37% black, with a mean age of 74 years.

SAN FRANCISCO — Spend plenty of time addressing parents' concerns about a child's vulvovaginal disease or their worries may contribute to the problem, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

When a skin lesion, pain, or itching develops in a girl's genital area, parents often become hypervigilant, inspecting the anogenital skin five or six times a day. "Parents will often ask, 'Honey, are you itching?' when the kid is sitting there watching television or not even thinking about it," causing the child to focus more on her symptoms, said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Some girls learn to get secondary gain from the problem, complaining of symptoms and asking a parent to look at the problem area, sometimes for attention and sometimes to avoid unwanted tasks.

The parents frequently worry about the implications of the problem. Does the child have cancer? Will she grow up to have normal sexual function? Will the child be able to have children later on? Will she be psychologically wounded from the genital problem? Parents "often need lots and lots of reassurance," she said.

By the time Dr. Edwards sees a referral for pediatric vulvovaginal disease, the child usually has been worked up for sexually transmitted disease, especially if there's an ulcer-like lesion present, "and the parents are unbelievably distraught," she added.

Irritant contact dermatitis is a common cause of vulvar inflammation, itching, or raw, burning sensations. Prepubertal genital skin is easily irritated, even more so than postmenopausal genital skin. Soaps, creams, bubble bath, urine, and diarrhea can cause itching or burning. Mothers often overwash the child's genital area in response, aggravating the problem.

Physicians compound the problem by prescribing antifungal medication for presumed yeast infection, a disease that is rare in girls after the diaper years and before puberty. "Topical antifungals do little more than irritate the skin" in most cases, she cautioned. If you suspect yeast infection in girls at higher risk for it—such as girls with obesity or diabetes—get a culture to confirm the diagnosis, she advised.

To treat irritant contact dermatitis in the vulvovaginal area, stop the irritant. Change diapers more often, if that's a factor. Stop any unnecessary medications. Apply a topical corticosteroid ointment, avoiding creams because they will burn and sting upon contact.

"Even on an intact vulva, cream is going to be more likely to burn a child than an adult," Dr. Edwards said.

For dosing, "I start high, and back off," usually with clobetasol ointment, she said. "I just wish they would come out with a 2-g tube," because the available tubes are too big for this indication, she added.

Have a strong discussion with parents about potential side effects if they overuse corticosteroids, give them a handout with warnings, do not prescribe refills, and have them bring the child back in 3–4 weeks, she suggested.

Never insert dry, cotton-tipped applicators into a child's introitus because this causes pain and may cause erosions. Moisten cotton-tipped applicators if you plan to use them on the vulva, and touch the skin but don't rub it.

Bland emollients to cover skin cracks and fissures can help reduce irritation and pain. Night-time sedation may be helpful if the child scratches while sleeping.

Lichen sclerosus is an uncommon cause of anogenital itching and irritation in prepubertal girls. It looks the same as in adults, except that children with the disease often have more irritation because their skin is so easily torn from scratching.

Treat by stopping any irritants and prescribing an ultrapotent topical corticosteroid ointment, which should resolve symptoms but not cure the disease. Like adults, children with lichen sclerosus will need ongoing therapy. Emphasize to parents that they should not stop therapy when symptoms resolve in 4–5 days, because recurrences can cause progressive, irreversible scarring, she said.

During the first 4–5 days of therapy, the immunosuppressive effects of corticosteroids increase the risk of secondary infection in the fragile, eroded skin, so oral antibiotics may be warranted, Dr. Edwards said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Spend plenty of time addressing parents' concerns about a child's vulvovaginal disease or their worries may contribute to the problem, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

When a skin lesion, pain, or itching develops in a girl's genital area, parents often become hypervigilant, inspecting the anogenital skin five or six times a day. "Parents will often ask, 'Honey, are you itching?' when the kid is sitting there watching television or not even thinking about it," causing the child to focus more on her symptoms, said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Some girls learn to get secondary gain from the problem, complaining of symptoms and asking a parent to look at the problem area, sometimes for attention and sometimes to avoid unwanted tasks.

The parents frequently worry about the implications of the problem. Does the child have cancer? Will she grow up to have normal sexual function? Will the child be able to have children later on? Will she be psychologically wounded from the genital problem? Parents "often need lots and lots of reassurance," she said.

By the time Dr. Edwards sees a referral for pediatric vulvovaginal disease, the child usually has been worked up for sexually transmitted disease, especially if there's an ulcer-like lesion present, "and the parents are unbelievably distraught," she added.

Irritant contact dermatitis is a common cause of vulvar inflammation, itching, or raw, burning sensations. Prepubertal genital skin is easily irritated, even more so than postmenopausal genital skin. Soaps, creams, bubble bath, urine, and diarrhea can cause itching or burning. Mothers often overwash the child's genital area in response, aggravating the problem.

Physicians compound the problem by prescribing antifungal medication for presumed yeast infection, a disease that is rare in girls after the diaper years and before puberty. "Topical antifungals do little more than irritate the skin" in most cases, she cautioned. If you suspect yeast infection in girls at higher risk for it—such as girls with obesity or diabetes—get a culture to confirm the diagnosis, she advised.

To treat irritant contact dermatitis in the vulvovaginal area, stop the irritant. Change diapers more often, if that's a factor. Stop any unnecessary medications. Apply a topical corticosteroid ointment, avoiding creams because they will burn and sting upon contact.

"Even on an intact vulva, cream is going to be more likely to burn a child than an adult," Dr. Edwards said.

For dosing, "I start high, and back off," usually with clobetasol ointment, she said. "I just wish they would come out with a 2-g tube," because the available tubes are too big for this indication, she added.

Have a strong discussion with parents about potential side effects if they overuse corticosteroids, give them a handout with warnings, do not prescribe refills, and have them bring the child back in 3–4 weeks, she suggested.

Never insert dry, cotton-tipped applicators into a child's introitus because this causes pain and may cause erosions. Moisten cotton-tipped applicators if you plan to use them on the vulva, and touch the skin but don't rub it.

Bland emollients to cover skin cracks and fissures can help reduce irritation and pain. Night-time sedation may be helpful if the child scratches while sleeping.

Lichen sclerosus is an uncommon cause of anogenital itching and irritation in prepubertal girls. It looks the same as in adults, except that children with the disease often have more irritation because their skin is so easily torn from scratching.

Treat by stopping any irritants and prescribing an ultrapotent topical corticosteroid ointment, which should resolve symptoms but not cure the disease. Like adults, children with lichen sclerosus will need ongoing therapy. Emphasize to parents that they should not stop therapy when symptoms resolve in 4–5 days, because recurrences can cause progressive, irreversible scarring, she said.

During the first 4–5 days of therapy, the immunosuppressive effects of corticosteroids increase the risk of secondary infection in the fragile, eroded skin, so oral antibiotics may be warranted, Dr. Edwards said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Spend plenty of time addressing parents' concerns about a child's vulvovaginal disease or their worries may contribute to the problem, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

When a skin lesion, pain, or itching develops in a girl's genital area, parents often become hypervigilant, inspecting the anogenital skin five or six times a day. "Parents will often ask, 'Honey, are you itching?' when the kid is sitting there watching television or not even thinking about it," causing the child to focus more on her symptoms, said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Some girls learn to get secondary gain from the problem, complaining of symptoms and asking a parent to look at the problem area, sometimes for attention and sometimes to avoid unwanted tasks.

The parents frequently worry about the implications of the problem. Does the child have cancer? Will she grow up to have normal sexual function? Will the child be able to have children later on? Will she be psychologically wounded from the genital problem? Parents "often need lots and lots of reassurance," she said.

By the time Dr. Edwards sees a referral for pediatric vulvovaginal disease, the child usually has been worked up for sexually transmitted disease, especially if there's an ulcer-like lesion present, "and the parents are unbelievably distraught," she added.

Irritant contact dermatitis is a common cause of vulvar inflammation, itching, or raw, burning sensations. Prepubertal genital skin is easily irritated, even more so than postmenopausal genital skin. Soaps, creams, bubble bath, urine, and diarrhea can cause itching or burning. Mothers often overwash the child's genital area in response, aggravating the problem.

Physicians compound the problem by prescribing antifungal medication for presumed yeast infection, a disease that is rare in girls after the diaper years and before puberty. "Topical antifungals do little more than irritate the skin" in most cases, she cautioned. If you suspect yeast infection in girls at higher risk for it—such as girls with obesity or diabetes—get a culture to confirm the diagnosis, she advised.

To treat irritant contact dermatitis in the vulvovaginal area, stop the irritant. Change diapers more often, if that's a factor. Stop any unnecessary medications. Apply a topical corticosteroid ointment, avoiding creams because they will burn and sting upon contact.

"Even on an intact vulva, cream is going to be more likely to burn a child than an adult," Dr. Edwards said.

For dosing, "I start high, and back off," usually with clobetasol ointment, she said. "I just wish they would come out with a 2-g tube," because the available tubes are too big for this indication, she added.

Have a strong discussion with parents about potential side effects if they overuse corticosteroids, give them a handout with warnings, do not prescribe refills, and have them bring the child back in 3–4 weeks, she suggested.

Never insert dry, cotton-tipped applicators into a child's introitus because this causes pain and may cause erosions. Moisten cotton-tipped applicators if you plan to use them on the vulva, and touch the skin but don't rub it.

Bland emollients to cover skin cracks and fissures can help reduce irritation and pain. Night-time sedation may be helpful if the child scratches while sleeping.

Lichen sclerosus is an uncommon cause of anogenital itching and irritation in prepubertal girls. It looks the same as in adults, except that children with the disease often have more irritation because their skin is so easily torn from scratching.

Treat by stopping any irritants and prescribing an ultrapotent topical corticosteroid ointment, which should resolve symptoms but not cure the disease. Like adults, children with lichen sclerosus will need ongoing therapy. Emphasize to parents that they should not stop therapy when symptoms resolve in 4–5 days, because recurrences can cause progressive, irreversible scarring, she said.

During the first 4–5 days of therapy, the immunosuppressive effects of corticosteroids increase the risk of secondary infection in the fragile, eroded skin, so oral antibiotics may be warranted, Dr. Edwards said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.