Betsy Bates

VANCOUVER, B.C. – Interpersonal therapy for adolescents–a “new kid on the block” for treating adolescent depression–puts relationships in the spotlight as a way to help teenagers get their lives back on track.

The guiding principle behind interpersonal therapy for adolescents (IPT-A) is straightforward, Lorraine Hathaway said at a conference sponsored by the North Pacific Pediatric Society.

“It relies on the notion that depression occurs in the context of relationships … [which] can either trigger symptoms or exacerbate the depression. Depression itself can also affect relationships, so there's an interaction.”

IPT-A was developed by Dr. Laura Mufson at Columbia University in New York. Performed in 12 semistructured sessions, the model focuses on a problem area (grief, role transition, role disputes, interpersonal deficits), with the aim of teasing out destructive and constructive relationship contributors and building skills that make relationships better.

“This makes sense to teenagers. They like it,” said Ms. Hathaway, MSW, a contributor to a mood and anxiety symposium sponsored by faculty members of the University of British Columbia and British Columbia Children's Hospital in Vancouver. Ms. Hathaway is coleading an IPT-A education project with Dr. Elizabeth Hall, a adolescent psychiatrist.

Dr. Susan Baer, an adolescent psychiatrist with the UBC Mood and Anxiety Disorders Clinic, said IPT is a new option among evidence-based strategies that can be used to treat adolescent depression, along with cognitive-behavioral therapy and medication.

Clinicians should be aware of it and, with training, can direct it themselves, Dr. Baer said.

“What's nice about this treatment is it takes basic, good counseling skills and clinical skills, and puts an overlay on them. It uses what you already know if you're a person used to talking to kids, and working with and counseling kids,” Ms. Hathaway said.

In interpersonal therapy, the therapist assists the adolescent in drawing a “depression circle,” topped by a precipitating event that has an impact on relationships and feelings. At the bottom of the circle are the individual's depression symptoms, which in turn, also are driven by and feed into events.

Next, the adolescent conducts an “interpersonal inventory” within concentric circles that represent the closeness of relationships. Which friends and family members are helpful? Which have pulled away?

Framing the context of his or her life allows an adolescent patient to begin to see how depression influences the picture.

The goal is to obtain symptom relief while improving interpersonal functioning and resolving overriding problem areas.

Parents are involved in the first and last session and and elsewhere as needed. Medication can be used in conjunction with IPT-A, but it is not necessary for all teens.

Obviously, each adolescent's experience is different, as will be the IPT-A skills that are required.

Ms. Hathaway used as an example the case of 15-year-old Pamela, whose mother suffered from major depression.

The breakup of a relationship, transfer of three friends to a new school, and a distant relationship with her parents all played a role in Pamela's depression, which was manifested in significant weight loss, suicidal ideation, cutting, poor concentration, irritability, insomnia, and a sharp decline in school performance and social interactions.

Pamela's job in IPT-A was to mourn the loss of her old role as a girlfriend and the close, day-to-day interactions with the former classmates. She needed to accept and work toward building competency and mastery in a new role.

To do this, she had to honestly assess the limits of individual friendships and relationships with family members. She also had to practice her communication skills, actually telling people close to her what she needed and expected from them, and what she was willing to give in return. She needed to make new friends and cultivate new interests.

Ms. Hathaway helped her to recognize how her moods affected relationships, and vice versa, and to practice active problem solving focused on the stresses in her life.

“Our work together is to help you to deal with this big change in your life, voicing your feelings about the relationship[s]. How do you pick up the pieces and go on and look for people who you can be happy with?” she asked.

In a video filmed 6 months after her IPT sessions ended, Pamela said that she realized in retrospect that she had been isolating herself. Her friends, both old and new, commented that she seemed like a new person.

Now, she said, “every second is precious. I'm really excited about biology. I'm actually really cherishing my life.”

VANCOUVER, B.C. – Interpersonal therapy for adolescents–a “new kid on the block” for treating adolescent depression–puts relationships in the spotlight as a way to help teenagers get their lives back on track.

The guiding principle behind interpersonal therapy for adolescents (IPT-A) is straightforward, Lorraine Hathaway said at a conference sponsored by the North Pacific Pediatric Society.

“It relies on the notion that depression occurs in the context of relationships … [which] can either trigger symptoms or exacerbate the depression. Depression itself can also affect relationships, so there's an interaction.”

IPT-A was developed by Dr. Laura Mufson at Columbia University in New York. Performed in 12 semistructured sessions, the model focuses on a problem area (grief, role transition, role disputes, interpersonal deficits), with the aim of teasing out destructive and constructive relationship contributors and building skills that make relationships better.

“This makes sense to teenagers. They like it,” said Ms. Hathaway, MSW, a contributor to a mood and anxiety symposium sponsored by faculty members of the University of British Columbia and British Columbia Children's Hospital in Vancouver. Ms. Hathaway is coleading an IPT-A education project with Dr. Elizabeth Hall, a adolescent psychiatrist.

Dr. Susan Baer, an adolescent psychiatrist with the UBC Mood and Anxiety Disorders Clinic, said IPT is a new option among evidence-based strategies that can be used to treat adolescent depression, along with cognitive-behavioral therapy and medication.

Clinicians should be aware of it and, with training, can direct it themselves, Dr. Baer said.

“What's nice about this treatment is it takes basic, good counseling skills and clinical skills, and puts an overlay on them. It uses what you already know if you're a person used to talking to kids, and working with and counseling kids,” Ms. Hathaway said.

In interpersonal therapy, the therapist assists the adolescent in drawing a “depression circle,” topped by a precipitating event that has an impact on relationships and feelings. At the bottom of the circle are the individual's depression symptoms, which in turn, also are driven by and feed into events.

Next, the adolescent conducts an “interpersonal inventory” within concentric circles that represent the closeness of relationships. Which friends and family members are helpful? Which have pulled away?

Framing the context of his or her life allows an adolescent patient to begin to see how depression influences the picture.

The goal is to obtain symptom relief while improving interpersonal functioning and resolving overriding problem areas.

Parents are involved in the first and last session and and elsewhere as needed. Medication can be used in conjunction with IPT-A, but it is not necessary for all teens.

Obviously, each adolescent's experience is different, as will be the IPT-A skills that are required.

Ms. Hathaway used as an example the case of 15-year-old Pamela, whose mother suffered from major depression.

The breakup of a relationship, transfer of three friends to a new school, and a distant relationship with her parents all played a role in Pamela's depression, which was manifested in significant weight loss, suicidal ideation, cutting, poor concentration, irritability, insomnia, and a sharp decline in school performance and social interactions.

Pamela's job in IPT-A was to mourn the loss of her old role as a girlfriend and the close, day-to-day interactions with the former classmates. She needed to accept and work toward building competency and mastery in a new role.

To do this, she had to honestly assess the limits of individual friendships and relationships with family members. She also had to practice her communication skills, actually telling people close to her what she needed and expected from them, and what she was willing to give in return. She needed to make new friends and cultivate new interests.

Ms. Hathaway helped her to recognize how her moods affected relationships, and vice versa, and to practice active problem solving focused on the stresses in her life.

“Our work together is to help you to deal with this big change in your life, voicing your feelings about the relationship[s]. How do you pick up the pieces and go on and look for people who you can be happy with?” she asked.

In a video filmed 6 months after her IPT sessions ended, Pamela said that she realized in retrospect that she had been isolating herself. Her friends, both old and new, commented that she seemed like a new person.

Now, she said, “every second is precious. I'm really excited about biology. I'm actually really cherishing my life.”

VANCOUVER, B.C. – Interpersonal therapy for adolescents–a “new kid on the block” for treating adolescent depression–puts relationships in the spotlight as a way to help teenagers get their lives back on track.

The guiding principle behind interpersonal therapy for adolescents (IPT-A) is straightforward, Lorraine Hathaway said at a conference sponsored by the North Pacific Pediatric Society.

“It relies on the notion that depression occurs in the context of relationships … [which] can either trigger symptoms or exacerbate the depression. Depression itself can also affect relationships, so there's an interaction.”

IPT-A was developed by Dr. Laura Mufson at Columbia University in New York. Performed in 12 semistructured sessions, the model focuses on a problem area (grief, role transition, role disputes, interpersonal deficits), with the aim of teasing out destructive and constructive relationship contributors and building skills that make relationships better.

“This makes sense to teenagers. They like it,” said Ms. Hathaway, MSW, a contributor to a mood and anxiety symposium sponsored by faculty members of the University of British Columbia and British Columbia Children's Hospital in Vancouver. Ms. Hathaway is coleading an IPT-A education project with Dr. Elizabeth Hall, a adolescent psychiatrist.

Dr. Susan Baer, an adolescent psychiatrist with the UBC Mood and Anxiety Disorders Clinic, said IPT is a new option among evidence-based strategies that can be used to treat adolescent depression, along with cognitive-behavioral therapy and medication.

Clinicians should be aware of it and, with training, can direct it themselves, Dr. Baer said.

“What's nice about this treatment is it takes basic, good counseling skills and clinical skills, and puts an overlay on them. It uses what you already know if you're a person used to talking to kids, and working with and counseling kids,” Ms. Hathaway said.

In interpersonal therapy, the therapist assists the adolescent in drawing a “depression circle,” topped by a precipitating event that has an impact on relationships and feelings. At the bottom of the circle are the individual's depression symptoms, which in turn, also are driven by and feed into events.

Next, the adolescent conducts an “interpersonal inventory” within concentric circles that represent the closeness of relationships. Which friends and family members are helpful? Which have pulled away?

Framing the context of his or her life allows an adolescent patient to begin to see how depression influences the picture.

The goal is to obtain symptom relief while improving interpersonal functioning and resolving overriding problem areas.

Parents are involved in the first and last session and and elsewhere as needed. Medication can be used in conjunction with IPT-A, but it is not necessary for all teens.

Obviously, each adolescent's experience is different, as will be the IPT-A skills that are required.

Ms. Hathaway used as an example the case of 15-year-old Pamela, whose mother suffered from major depression.

The breakup of a relationship, transfer of three friends to a new school, and a distant relationship with her parents all played a role in Pamela's depression, which was manifested in significant weight loss, suicidal ideation, cutting, poor concentration, irritability, insomnia, and a sharp decline in school performance and social interactions.

Pamela's job in IPT-A was to mourn the loss of her old role as a girlfriend and the close, day-to-day interactions with the former classmates. She needed to accept and work toward building competency and mastery in a new role.

To do this, she had to honestly assess the limits of individual friendships and relationships with family members. She also had to practice her communication skills, actually telling people close to her what she needed and expected from them, and what she was willing to give in return. She needed to make new friends and cultivate new interests.

Ms. Hathaway helped her to recognize how her moods affected relationships, and vice versa, and to practice active problem solving focused on the stresses in her life.

“Our work together is to help you to deal with this big change in your life, voicing your feelings about the relationship[s]. How do you pick up the pieces and go on and look for people who you can be happy with?” she asked.

In a video filmed 6 months after her IPT sessions ended, Pamela said that she realized in retrospect that she had been isolating herself. Her friends, both old and new, commented that she seemed like a new person.

Now, she said, “every second is precious. I'm really excited about biology. I'm actually really cherishing my life.”

PORTLAND, ORE. — Getting an early read on the personalities and motivations of cosmetic dermatology patients will help avoid negative outcomes, unfair refund requests, and, perhaps most importantly, patients with body dysmorphic disorder, said Dr. William Philip Werschler at annual meeting of the Pacific Northwest Dermatological Society.

He draws parallels between cosmetic dermatology patients and car buyers: There's the brand loyalist, a great kind of patient to have, since he or she always comes to you for care. Better the brand loyalist than the negotiator or the tire kicker.

Status seekers fill your waiting room on their way to the local Jaguar dealership, and they can be good patients as long as they are not unduly influenced by the society maven down the street or the cover model on Vogue, said Dr. Werschler of the department of dermatology at the University of Washington, Spokane.

The special event buyer, on the other hand, has you scheduled in her prewedding or reunion planning book, not unlike the 50th-birthday Ferrari shopper.

Once you've sorted them all out, Dr. Werschler suggests guarding against the one thing that is the bane of the car dealer's existence and which could be a common occurrence: buyer's remorse.

"It's not a tent at Cabela's [camping outfitters]," Dr. Werschler said. "You can't suck it back out and give them a refund."

Buyer's remorse can be short circuited before the procedure by underpromising and overdelivering results, charging fair prices, and turning down patients who exhibit signs of bad consumer behavior or body dysmorphic disorder.

"It's okay to say no," he said. "Plastic surgeons do it all the time."

Another tip that dermatologists could borrow from plastic surgeons concerns refunds, which Dr. Werschler said should never be offered just to get a difficult patient out of the office.

When he encounters a patient who is dissatisfied with objectively good results, Dr. Werschler said he is quick to express empathy without accepting blame. For example, he'll say, "I've done my best. The laser did its best. I know you did your best."

He then describes possible alternative procedures the patient could invest in to achieve more pleasing results.

However, he won't operate on patients with body dysmorphic disorder, a somatoform disorder in which a person perceives deficits in physical traits that are actually within normal limits.

Clues to identify such patients may include the lack of visible problems upon examination, incessant self-grooming during the visit, and, especially, a history of unnecessary dermatologic and/or plastic surgery procedures.

Dr. Werschler says he believes in using a direct approach with patients who have an underlying psychiatric disorder that drives them to seek repeated procedures.

By asking if they believe they might have a problem, dermatologists may help these patients get off "the merry-go-round" of procedure after unfulfilling procedure, he said.

Thinking About Adding Aesthetics?

1. Are you sufficiently interested to keep up with the field? Cosmetic procedures fall into the category of "fast-moving consumer goods," like perfumes and hair products, Dr. Werschler said. You need to offer the newest procedures.

2. Are you capable? Do you have steady hands and good hand-eye coordination? Precise surgical skills are needed to achieve excellent cosmetic results.

3. Do you have a good aesthetic sense? Can you subjugate that sense, even when the patient's aesthetic sense is shaky at best?

4. Can you handle whiners? Cosmetics patients can be demanding and difficult to please.

5. Can you say no? No cosmetic practice can succeed unless the physician turns away impossible-to-please patients and refuses to cave in to frivolous refund requests.

Source: Dr. Werschler

PORTLAND, ORE. — Getting an early read on the personalities and motivations of cosmetic dermatology patients will help avoid negative outcomes, unfair refund requests, and, perhaps most importantly, patients with body dysmorphic disorder, said Dr. William Philip Werschler at annual meeting of the Pacific Northwest Dermatological Society.

He draws parallels between cosmetic dermatology patients and car buyers: There's the brand loyalist, a great kind of patient to have, since he or she always comes to you for care. Better the brand loyalist than the negotiator or the tire kicker.

Status seekers fill your waiting room on their way to the local Jaguar dealership, and they can be good patients as long as they are not unduly influenced by the society maven down the street or the cover model on Vogue, said Dr. Werschler of the department of dermatology at the University of Washington, Spokane.

The special event buyer, on the other hand, has you scheduled in her prewedding or reunion planning book, not unlike the 50th-birthday Ferrari shopper.

Once you've sorted them all out, Dr. Werschler suggests guarding against the one thing that is the bane of the car dealer's existence and which could be a common occurrence: buyer's remorse.

"It's not a tent at Cabela's [camping outfitters]," Dr. Werschler said. "You can't suck it back out and give them a refund."

Buyer's remorse can be short circuited before the procedure by underpromising and overdelivering results, charging fair prices, and turning down patients who exhibit signs of bad consumer behavior or body dysmorphic disorder.

"It's okay to say no," he said. "Plastic surgeons do it all the time."

Another tip that dermatologists could borrow from plastic surgeons concerns refunds, which Dr. Werschler said should never be offered just to get a difficult patient out of the office.

When he encounters a patient who is dissatisfied with objectively good results, Dr. Werschler said he is quick to express empathy without accepting blame. For example, he'll say, "I've done my best. The laser did its best. I know you did your best."

He then describes possible alternative procedures the patient could invest in to achieve more pleasing results.

However, he won't operate on patients with body dysmorphic disorder, a somatoform disorder in which a person perceives deficits in physical traits that are actually within normal limits.

Clues to identify such patients may include the lack of visible problems upon examination, incessant self-grooming during the visit, and, especially, a history of unnecessary dermatologic and/or plastic surgery procedures.

Dr. Werschler says he believes in using a direct approach with patients who have an underlying psychiatric disorder that drives them to seek repeated procedures.

By asking if they believe they might have a problem, dermatologists may help these patients get off "the merry-go-round" of procedure after unfulfilling procedure, he said.

Thinking About Adding Aesthetics?

1. Are you sufficiently interested to keep up with the field? Cosmetic procedures fall into the category of "fast-moving consumer goods," like perfumes and hair products, Dr. Werschler said. You need to offer the newest procedures.

2. Are you capable? Do you have steady hands and good hand-eye coordination? Precise surgical skills are needed to achieve excellent cosmetic results.

3. Do you have a good aesthetic sense? Can you subjugate that sense, even when the patient's aesthetic sense is shaky at best?

4. Can you handle whiners? Cosmetics patients can be demanding and difficult to please.

5. Can you say no? No cosmetic practice can succeed unless the physician turns away impossible-to-please patients and refuses to cave in to frivolous refund requests.

Source: Dr. Werschler

PORTLAND, ORE. — Getting an early read on the personalities and motivations of cosmetic dermatology patients will help avoid negative outcomes, unfair refund requests, and, perhaps most importantly, patients with body dysmorphic disorder, said Dr. William Philip Werschler at annual meeting of the Pacific Northwest Dermatological Society.

He draws parallels between cosmetic dermatology patients and car buyers: There's the brand loyalist, a great kind of patient to have, since he or she always comes to you for care. Better the brand loyalist than the negotiator or the tire kicker.

Status seekers fill your waiting room on their way to the local Jaguar dealership, and they can be good patients as long as they are not unduly influenced by the society maven down the street or the cover model on Vogue, said Dr. Werschler of the department of dermatology at the University of Washington, Spokane.

The special event buyer, on the other hand, has you scheduled in her prewedding or reunion planning book, not unlike the 50th-birthday Ferrari shopper.

Once you've sorted them all out, Dr. Werschler suggests guarding against the one thing that is the bane of the car dealer's existence and which could be a common occurrence: buyer's remorse.

"It's not a tent at Cabela's [camping outfitters]," Dr. Werschler said. "You can't suck it back out and give them a refund."

Buyer's remorse can be short circuited before the procedure by underpromising and overdelivering results, charging fair prices, and turning down patients who exhibit signs of bad consumer behavior or body dysmorphic disorder.

"It's okay to say no," he said. "Plastic surgeons do it all the time."

Another tip that dermatologists could borrow from plastic surgeons concerns refunds, which Dr. Werschler said should never be offered just to get a difficult patient out of the office.

When he encounters a patient who is dissatisfied with objectively good results, Dr. Werschler said he is quick to express empathy without accepting blame. For example, he'll say, "I've done my best. The laser did its best. I know you did your best."

He then describes possible alternative procedures the patient could invest in to achieve more pleasing results.

However, he won't operate on patients with body dysmorphic disorder, a somatoform disorder in which a person perceives deficits in physical traits that are actually within normal limits.

Clues to identify such patients may include the lack of visible problems upon examination, incessant self-grooming during the visit, and, especially, a history of unnecessary dermatologic and/or plastic surgery procedures.

Dr. Werschler says he believes in using a direct approach with patients who have an underlying psychiatric disorder that drives them to seek repeated procedures.

By asking if they believe they might have a problem, dermatologists may help these patients get off "the merry-go-round" of procedure after unfulfilling procedure, he said.

Thinking About Adding Aesthetics?

1. Are you sufficiently interested to keep up with the field? Cosmetic procedures fall into the category of "fast-moving consumer goods," like perfumes and hair products, Dr. Werschler said. You need to offer the newest procedures.

2. Are you capable? Do you have steady hands and good hand-eye coordination? Precise surgical skills are needed to achieve excellent cosmetic results.

3. Do you have a good aesthetic sense? Can you subjugate that sense, even when the patient's aesthetic sense is shaky at best?

4. Can you handle whiners? Cosmetics patients can be demanding and difficult to please.

5. Can you say no? No cosmetic practice can succeed unless the physician turns away impossible-to-please patients and refuses to cave in to frivolous refund requests.

Source: Dr. Werschler

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large Kaiser Permanente study presented by Dr. Seth L. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group.

Dr. Feigenbaum and associates at the 3.3-million-member Kaiser Permanente Health Plan of Northern California compared 6,671 women ages 16–44 who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

The sample represents 42% of insured individuals in northern California and is highly representative of the racial and ethnic diversity of the 14 counties of the San Francisco Bay vicinity, Dr. Feigenbaum said at the annual meeting of the Pacific Coast Reproductive Society.

Two-thirds of women with a diagnosis of PCOS were obese—having a body mass index of 30 kg/m

Compared with white women, black and Hispanic women with PCOS were significantly more likely, and Asian women were significantly less likely, to be obese.

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks.

In a multivariate regression analysis that adjusted for variables such as BMI, distinct racial/ethnic patterns emerged:

▸ Asians had a twofold increased risk of diabetes, compared with whites

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites, with odds ratios of 1.33 and 0.68, respectively.

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large Kaiser Permanente study presented by Dr. Seth L. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group.

Dr. Feigenbaum and associates at the 3.3-million-member Kaiser Permanente Health Plan of Northern California compared 6,671 women ages 16–44 who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

The sample represents 42% of insured individuals in northern California and is highly representative of the racial and ethnic diversity of the 14 counties of the San Francisco Bay vicinity, Dr. Feigenbaum said at the annual meeting of the Pacific Coast Reproductive Society.

Two-thirds of women with a diagnosis of PCOS were obese—having a body mass index of 30 kg/m

Compared with white women, black and Hispanic women with PCOS were significantly more likely, and Asian women were significantly less likely, to be obese.

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks.

In a multivariate regression analysis that adjusted for variables such as BMI, distinct racial/ethnic patterns emerged:

▸ Asians had a twofold increased risk of diabetes, compared with whites

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites, with odds ratios of 1.33 and 0.68, respectively.

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large Kaiser Permanente study presented by Dr. Seth L. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group.

Dr. Feigenbaum and associates at the 3.3-million-member Kaiser Permanente Health Plan of Northern California compared 6,671 women ages 16–44 who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

The sample represents 42% of insured individuals in northern California and is highly representative of the racial and ethnic diversity of the 14 counties of the San Francisco Bay vicinity, Dr. Feigenbaum said at the annual meeting of the Pacific Coast Reproductive Society.

Two-thirds of women with a diagnosis of PCOS were obese—having a body mass index of 30 kg/m

Compared with white women, black and Hispanic women with PCOS were significantly more likely, and Asian women were significantly less likely, to be obese.

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks.

In a multivariate regression analysis that adjusted for variables such as BMI, distinct racial/ethnic patterns emerged:

▸ Asians had a twofold increased risk of diabetes, compared with whites

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites, with odds ratios of 1.33 and 0.68, respectively.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false positive rate of 5% with virtual colonoscopy.

Conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 lesions that were less than 6 mm, 27 that were between 6 mm and 9 mm, and 12 that were greater than 9 mm. Most of them were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false positive rate of 5% with virtual colonoscopy.

Conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 lesions that were less than 6 mm, 27 that were between 6 mm and 9 mm, and 12 that were greater than 9 mm. Most of them were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

LOS ANGELES — Virtual colonoscopy missed adenomatous lesions in 12% of patients, including 5% who had advanced lesions detected only on a follow-up optical colonoscopy, researchers reported at the annual Digestive Disease Week.

Investigators at the University of Wisconsin, Madison, studied records of 160 patients who first had virtual colonoscopy performed by primary 3-D read with 2-D resolution and were then sent for optical colonoscopy.

Patients had both tests if a significant portion of the colon was not visualized on virtual colonoscopy, if they had findings of a polyp or mass greater than 10 mm, if virtual colonoscopy detected polyps between 6 mm and 9 mm, or at the patient's discretion. Lesions less than 6 mm that were seen on virtual colonoscopy were not reported, and patients with these lesions were not referred for optical colonoscopy.

Invasive colonoscopy detected adenomatous lesions not seen on virtual colonoscopy in 19 of 160 patients. Eight of these patients had previously undetected advanced lesions, defined as any adenoma greater than 9 mm or a lesion less than 9 mm with villous pathology.

The second test also detected a false positive rate of 5% with virtual colonoscopy.

Conventional colonoscopy detected 138 lesions, in 54 patients, that had not been seen on virtual colonoscopy, including 99 lesions that were less than 6 mm, 27 that were between 6 mm and 9 mm, and 12 that were greater than 9 mm. Most of them were hyperplastic.

“These findings suggest that virtual colonoscopy identifies the majority of colorectal polyps with advanced pathology during routine screening examinations,” said Dr. Daniel Cornett of the section of gastroenterology and hepatology at the University of Wisconsin, Madison.

But he added that virtual colonoscopy poses a “small risk” of missing polyps with advanced pathology, “especially smaller polyps less than 9 mm in size with villous pathology and larger adenomas that are flat in nature or resemble a mucosal fold.”

Both Dr. Cornett and coauthor Dr. Courtney Barancin, a gastroenterology fellow, expressed concern that some protocols for virtual colonoscopy do not refer for optical colonoscopy patients with lesions less than 6 mm.

PORTLAND, ORE. — Cosmetic nails are here to stay, so physicians would do well to learn about the glittery accessories driving a $6.8 billion a year industry, Dr. Phoebe Rich said at the Pacific Northwest Dermatological annual scientific conference.

“Nail cosmetics are not inherently dangerous,” the Portland, Ore.-based dermatologist stressed. “They're used by millions of women who really don't have any trouble at all with them.” However, when trouble does brew beneath the bright, rock-hard surfaces of acrylic nails, it can be nasty.

Dr. Rich offered these tips on nail cosmetics complications:

▸ Allergic reactions. Many allergens are involved in the process of creating artificial nails, but the site of the reaction will often reveal the source of the problem, she said.

Patients whose itching and burning is centered in the periungual and subungual regions probably have an acrylic allergy. “This material polymerizes very quickly, in less than a minute,” she said.

The allergen is basically trapped at the site where it is applied.

Enamel nail polish, on the other hand, may continue to induce dermatitis until the substance fully dries, which may take up to 48 hours. You may see reactions anywhere the patient's fingers touched: on the face, neck, or eyelids, for example.

Dr. Rich noted that a host of sensitizing agents are available in nail products that can be purchased at the local drugstore, not just in professional salons. An example is formaldehyde, an ingredient in Nail Magic, a nail hardening product that is not supposed to come in contact with the skin, but does, of course.

Many upscale nail salons are replacing highly allergenic materials with more expensive, less durable alternatives in response to customer allergies, she said.

▸ Irritant reactions. Nail polish remover containing acetone or acetate is the No. 1 culprit in drying out the nails, causing brittleness, fragility, onycholysis, paronychia, and friable keratin granulations.

There is a new alternative available over the Internet for sensitive patients: a water-based nail enamel that avoids the need for nail polish remover, since it peels off the nails or can be taken off using ethyl alcohol.

The nail colors sold at www.naturellacosmetics.com

▸ Trauma. “Women who are the most successful at using acrylic nails keep them short,” Dr. Rich explained.

“A long nail acts as a lever,” prying the rigid artificial nail off the nail bed, just as it did when one of Dr. Rich's patients caught her nail in the hinge of a lawn chair.

A natural nail, by contrast, is flexible, and would bend or break in such a scenario.

▸ Infection. The vivid, nearly impenetrable nail colors painted on cosmetic nails can hide all manner of infections, from “red-hot staph infections,” to onychomycosis “teeming with yeast.”

One problem is disruption of the cuticle with “clippers, drills, and all these little implements that they use to poke and prod and scrape.”

A word to patients to “nurture your cuticles” could help to avoid problems that arise because when aggressive cuticle trimming provides access to organisms that thrive in the moist, dark, warm place underneath the nail.

Infection sources in nail salons are reused files (which cannot be easily sterilized) and improperly cleaned pedicure tubs, which can incubate bacteria that find hospitable hosts in each pair of newly shaved legs that dip into the warm water baths they contain.

PORTLAND, ORE. — Cosmetic nails are here to stay, so physicians would do well to learn about the glittery accessories driving a $6.8 billion a year industry, Dr. Phoebe Rich said at the Pacific Northwest Dermatological annual scientific conference.

“Nail cosmetics are not inherently dangerous,” the Portland, Ore.-based dermatologist stressed. “They're used by millions of women who really don't have any trouble at all with them.” However, when trouble does brew beneath the bright, rock-hard surfaces of acrylic nails, it can be nasty.

Dr. Rich offered these tips on nail cosmetics complications:

▸ Allergic reactions. Many allergens are involved in the process of creating artificial nails, but the site of the reaction will often reveal the source of the problem, she said.

Patients whose itching and burning is centered in the periungual and subungual regions probably have an acrylic allergy. “This material polymerizes very quickly, in less than a minute,” she said.

The allergen is basically trapped at the site where it is applied.

Enamel nail polish, on the other hand, may continue to induce dermatitis until the substance fully dries, which may take up to 48 hours. You may see reactions anywhere the patient's fingers touched: on the face, neck, or eyelids, for example.

Dr. Rich noted that a host of sensitizing agents are available in nail products that can be purchased at the local drugstore, not just in professional salons. An example is formaldehyde, an ingredient in Nail Magic, a nail hardening product that is not supposed to come in contact with the skin, but does, of course.

Many upscale nail salons are replacing highly allergenic materials with more expensive, less durable alternatives in response to customer allergies, she said.

▸ Irritant reactions. Nail polish remover containing acetone or acetate is the No. 1 culprit in drying out the nails, causing brittleness, fragility, onycholysis, paronychia, and friable keratin granulations.

There is a new alternative available over the Internet for sensitive patients: a water-based nail enamel that avoids the need for nail polish remover, since it peels off the nails or can be taken off using ethyl alcohol.

The nail colors sold at www.naturellacosmetics.com

▸ Trauma. “Women who are the most successful at using acrylic nails keep them short,” Dr. Rich explained.

“A long nail acts as a lever,” prying the rigid artificial nail off the nail bed, just as it did when one of Dr. Rich's patients caught her nail in the hinge of a lawn chair.

A natural nail, by contrast, is flexible, and would bend or break in such a scenario.

▸ Infection. The vivid, nearly impenetrable nail colors painted on cosmetic nails can hide all manner of infections, from “red-hot staph infections,” to onychomycosis “teeming with yeast.”

One problem is disruption of the cuticle with “clippers, drills, and all these little implements that they use to poke and prod and scrape.”

A word to patients to “nurture your cuticles” could help to avoid problems that arise because when aggressive cuticle trimming provides access to organisms that thrive in the moist, dark, warm place underneath the nail.

Infection sources in nail salons are reused files (which cannot be easily sterilized) and improperly cleaned pedicure tubs, which can incubate bacteria that find hospitable hosts in each pair of newly shaved legs that dip into the warm water baths they contain.

PORTLAND, ORE. — Cosmetic nails are here to stay, so physicians would do well to learn about the glittery accessories driving a $6.8 billion a year industry, Dr. Phoebe Rich said at the Pacific Northwest Dermatological annual scientific conference.

“Nail cosmetics are not inherently dangerous,” the Portland, Ore.-based dermatologist stressed. “They're used by millions of women who really don't have any trouble at all with them.” However, when trouble does brew beneath the bright, rock-hard surfaces of acrylic nails, it can be nasty.

Dr. Rich offered these tips on nail cosmetics complications:

▸ Allergic reactions. Many allergens are involved in the process of creating artificial nails, but the site of the reaction will often reveal the source of the problem, she said.

Patients whose itching and burning is centered in the periungual and subungual regions probably have an acrylic allergy. “This material polymerizes very quickly, in less than a minute,” she said.

The allergen is basically trapped at the site where it is applied.

Enamel nail polish, on the other hand, may continue to induce dermatitis until the substance fully dries, which may take up to 48 hours. You may see reactions anywhere the patient's fingers touched: on the face, neck, or eyelids, for example.

Dr. Rich noted that a host of sensitizing agents are available in nail products that can be purchased at the local drugstore, not just in professional salons. An example is formaldehyde, an ingredient in Nail Magic, a nail hardening product that is not supposed to come in contact with the skin, but does, of course.

Many upscale nail salons are replacing highly allergenic materials with more expensive, less durable alternatives in response to customer allergies, she said.

▸ Irritant reactions. Nail polish remover containing acetone or acetate is the No. 1 culprit in drying out the nails, causing brittleness, fragility, onycholysis, paronychia, and friable keratin granulations.

There is a new alternative available over the Internet for sensitive patients: a water-based nail enamel that avoids the need for nail polish remover, since it peels off the nails or can be taken off using ethyl alcohol.

The nail colors sold at www.naturellacosmetics.com

▸ Trauma. “Women who are the most successful at using acrylic nails keep them short,” Dr. Rich explained.

“A long nail acts as a lever,” prying the rigid artificial nail off the nail bed, just as it did when one of Dr. Rich's patients caught her nail in the hinge of a lawn chair.

A natural nail, by contrast, is flexible, and would bend or break in such a scenario.

▸ Infection. The vivid, nearly impenetrable nail colors painted on cosmetic nails can hide all manner of infections, from “red-hot staph infections,” to onychomycosis “teeming with yeast.”

One problem is disruption of the cuticle with “clippers, drills, and all these little implements that they use to poke and prod and scrape.”

A word to patients to “nurture your cuticles” could help to avoid problems that arise because when aggressive cuticle trimming provides access to organisms that thrive in the moist, dark, warm place underneath the nail.

Infection sources in nail salons are reused files (which cannot be easily sterilized) and improperly cleaned pedicure tubs, which can incubate bacteria that find hospitable hosts in each pair of newly shaved legs that dip into the warm water baths they contain.

LOS ANGELES — Primary prevention of diabetes begins with the prevention of obesity, as well as maintaining the ABCs of normal metabolism: hemoglobin A_1c, blood pressure, and cholesterol, according to new nutrition guidelines from the American Diabetes Association.

Judith Wylie-Rosett, Ed.D., offered a sneak preview of the new guidelines at the annual meeting of the American Association of Diabetes Educators.

The guidelines, which will be published in this month's issue of Diabetes Care, are intended to complement recent nutrition guidelines by the American Heart Association (Circulation 2006;114:82–96).

The guidelines share a focus on obesity, said Dr. Wylie-Rosett, professor of epidemiology and population health at the Albert Einstein College of Medicine in New York. Both guidelines stop short of offering advice on specific nutrients that are thought to prevent disease.

In the diabetes guidelines, available evidence is ranked according to whether it is backed up by well-conducted, generalizable, randomized or multicenter trials (level A evidence), by well-controlled cohort studies or metaanalyses (level B evidence), or, less powerfully, by supportive data (level C) or expert opinion (level D).

The strongest evidence (level A) was cited for the importance of monitoring carbohydrate intake as “a key strategy in achieving glycemic control,” and the fact that “sucrose-containing foods can be substituted for other carbohydrates in the meal plan, or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Fiber and protein are encouraged, but the guidelines note that evidence is lacking on whether people with diabetes need to modify the intake of these food sources beyond what is recommended for healthy adults.

In terms of structure, the diabetes guidelines break down into evidence addressing obesity, prediabetes, overt diabetes, and diabetes complications. For example, the guidelines cite level B evidence for the use of weight loss medications, which “may be useful in overweight/obese individuals with type 2 diabetes” for achieving a 5%–10% weight loss when combined with lifestyle change.

In general, the guidelines advise the limitation of food choices “only to the extent that we have evidence that it will be of benefit,” said Dr. Wylie-Rosett.

The guidelines also lend strong credence to the safety of sugar alcohols and nonnutritive sweeteners within Food and Drug Administration-recommended daily intake levels.

Dr. Wylie-Rosett said in an interview that the ADA is increasingly stressing the potential importance of the contribution of sugar, especially sugary beverages, to overall calorie intake. However, the new guidelines do not recommend low carbohydrate diets (less than 130 g).

“Although such diets produce short-term weight loss, maintenance of weight loss is similar to that from low-fat diets, and impact on cardiovascular disease risk is unknown,” they state, citing level B evidence.

LOS ANGELES — Primary prevention of diabetes begins with the prevention of obesity, as well as maintaining the ABCs of normal metabolism: hemoglobin A_1c, blood pressure, and cholesterol, according to new nutrition guidelines from the American Diabetes Association.

Judith Wylie-Rosett, Ed.D., offered a sneak preview of the new guidelines at the annual meeting of the American Association of Diabetes Educators.

The guidelines, which will be published in this month's issue of Diabetes Care, are intended to complement recent nutrition guidelines by the American Heart Association (Circulation 2006;114:82–96).

The guidelines share a focus on obesity, said Dr. Wylie-Rosett, professor of epidemiology and population health at the Albert Einstein College of Medicine in New York. Both guidelines stop short of offering advice on specific nutrients that are thought to prevent disease.

In the diabetes guidelines, available evidence is ranked according to whether it is backed up by well-conducted, generalizable, randomized or multicenter trials (level A evidence), by well-controlled cohort studies or metaanalyses (level B evidence), or, less powerfully, by supportive data (level C) or expert opinion (level D).

The strongest evidence (level A) was cited for the importance of monitoring carbohydrate intake as “a key strategy in achieving glycemic control,” and the fact that “sucrose-containing foods can be substituted for other carbohydrates in the meal plan, or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Fiber and protein are encouraged, but the guidelines note that evidence is lacking on whether people with diabetes need to modify the intake of these food sources beyond what is recommended for healthy adults.

In terms of structure, the diabetes guidelines break down into evidence addressing obesity, prediabetes, overt diabetes, and diabetes complications. For example, the guidelines cite level B evidence for the use of weight loss medications, which “may be useful in overweight/obese individuals with type 2 diabetes” for achieving a 5%–10% weight loss when combined with lifestyle change.

In general, the guidelines advise the limitation of food choices “only to the extent that we have evidence that it will be of benefit,” said Dr. Wylie-Rosett.

The guidelines also lend strong credence to the safety of sugar alcohols and nonnutritive sweeteners within Food and Drug Administration-recommended daily intake levels.

Dr. Wylie-Rosett said in an interview that the ADA is increasingly stressing the potential importance of the contribution of sugar, especially sugary beverages, to overall calorie intake. However, the new guidelines do not recommend low carbohydrate diets (less than 130 g).

“Although such diets produce short-term weight loss, maintenance of weight loss is similar to that from low-fat diets, and impact on cardiovascular disease risk is unknown,” they state, citing level B evidence.

LOS ANGELES — Primary prevention of diabetes begins with the prevention of obesity, as well as maintaining the ABCs of normal metabolism: hemoglobin A_1c, blood pressure, and cholesterol, according to new nutrition guidelines from the American Diabetes Association.

Judith Wylie-Rosett, Ed.D., offered a sneak preview of the new guidelines at the annual meeting of the American Association of Diabetes Educators.

The guidelines, which will be published in this month's issue of Diabetes Care, are intended to complement recent nutrition guidelines by the American Heart Association (Circulation 2006;114:82–96).

The guidelines share a focus on obesity, said Dr. Wylie-Rosett, professor of epidemiology and population health at the Albert Einstein College of Medicine in New York. Both guidelines stop short of offering advice on specific nutrients that are thought to prevent disease.

In the diabetes guidelines, available evidence is ranked according to whether it is backed up by well-conducted, generalizable, randomized or multicenter trials (level A evidence), by well-controlled cohort studies or metaanalyses (level B evidence), or, less powerfully, by supportive data (level C) or expert opinion (level D).

The strongest evidence (level A) was cited for the importance of monitoring carbohydrate intake as “a key strategy in achieving glycemic control,” and the fact that “sucrose-containing foods can be substituted for other carbohydrates in the meal plan, or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Fiber and protein are encouraged, but the guidelines note that evidence is lacking on whether people with diabetes need to modify the intake of these food sources beyond what is recommended for healthy adults.

In terms of structure, the diabetes guidelines break down into evidence addressing obesity, prediabetes, overt diabetes, and diabetes complications. For example, the guidelines cite level B evidence for the use of weight loss medications, which “may be useful in overweight/obese individuals with type 2 diabetes” for achieving a 5%–10% weight loss when combined with lifestyle change.

In general, the guidelines advise the limitation of food choices “only to the extent that we have evidence that it will be of benefit,” said Dr. Wylie-Rosett.

The guidelines also lend strong credence to the safety of sugar alcohols and nonnutritive sweeteners within Food and Drug Administration-recommended daily intake levels.

Dr. Wylie-Rosett said in an interview that the ADA is increasingly stressing the potential importance of the contribution of sugar, especially sugary beverages, to overall calorie intake. However, the new guidelines do not recommend low carbohydrate diets (less than 130 g).

“Although such diets produce short-term weight loss, maintenance of weight loss is similar to that from low-fat diets, and impact on cardiovascular disease risk is unknown,” they state, citing level B evidence.

TUCSON, ARIZ. — A homemade stool-bulking agent was just as effective as commercial psyllium in relieving symptoms of constipation in a randomized trial conducted by researchers at the University of Texas Southwestern Medical Center in Dallas.

The recipe containing applesauce, unprocessed wheat bran, and prune juice cost about half as much as a commercial psyllium product, Konsyl, reported Dr. Peter Drewes and his associates from the medical center in a poster presented at the annual meeting of the Society of Gynecologic Surgeons.

Subjects for the trial were drawn from patients presenting to the university's urogynecology clinic who met Rome II criteria for constipation.

A total of 82 patients were randomized and 53 completed the 6-week study, including 30 randomized to take 1 teaspoon of psyllium in 8 ounces of liquid daily for 6 weeks or 4 tablespoons a day of the bowel recipe. All subjects received educational information on how dietary choices and fluids can influence constipation. They all kept bowel diaries. Results were calculated using pre- and posttrial scores on a 30-point constipation scoring system, with a higher score indicating more severe constipation.

Constipation was relieved in both groups, with scores declining from 13.9 to 9.0 for the psyllium users and 13.6 to 8.5 for the recipe users during the 6-week trial.

The cost of 6 weeks' worth of the bowel recipe was $8.65, compared with $16.72 for the commercial psyllium product.

The authors concluded that the homemade recipe was “an effective and economical stool-bulking agent for the treatment of constipation.”

Pantry Remedy For Constipation

1 cup applesauce

1 cup coarse, unprocessed wheat bran

1/4 cup prune juice

Source: Dr. Drewes

TUCSON, ARIZ. — A homemade stool-bulking agent was just as effective as commercial psyllium in relieving symptoms of constipation in a randomized trial conducted by researchers at the University of Texas Southwestern Medical Center in Dallas.

The recipe containing applesauce, unprocessed wheat bran, and prune juice cost about half as much as a commercial psyllium product, Konsyl, reported Dr. Peter Drewes and his associates from the medical center in a poster presented at the annual meeting of the Society of Gynecologic Surgeons.

Subjects for the trial were drawn from patients presenting to the university's urogynecology clinic who met Rome II criteria for constipation.

A total of 82 patients were randomized and 53 completed the 6-week study, including 30 randomized to take 1 teaspoon of psyllium in 8 ounces of liquid daily for 6 weeks or 4 tablespoons a day of the bowel recipe. All subjects received educational information on how dietary choices and fluids can influence constipation. They all kept bowel diaries. Results were calculated using pre- and posttrial scores on a 30-point constipation scoring system, with a higher score indicating more severe constipation.

Constipation was relieved in both groups, with scores declining from 13.9 to 9.0 for the psyllium users and 13.6 to 8.5 for the recipe users during the 6-week trial.

The cost of 6 weeks' worth of the bowel recipe was $8.65, compared with $16.72 for the commercial psyllium product.

The authors concluded that the homemade recipe was “an effective and economical stool-bulking agent for the treatment of constipation.”

Pantry Remedy For Constipation

1 cup applesauce

1 cup coarse, unprocessed wheat bran

1/4 cup prune juice

Source: Dr. Drewes

TUCSON, ARIZ. — A homemade stool-bulking agent was just as effective as commercial psyllium in relieving symptoms of constipation in a randomized trial conducted by researchers at the University of Texas Southwestern Medical Center in Dallas.

The recipe containing applesauce, unprocessed wheat bran, and prune juice cost about half as much as a commercial psyllium product, Konsyl, reported Dr. Peter Drewes and his associates from the medical center in a poster presented at the annual meeting of the Society of Gynecologic Surgeons.

Subjects for the trial were drawn from patients presenting to the university's urogynecology clinic who met Rome II criteria for constipation.

A total of 82 patients were randomized and 53 completed the 6-week study, including 30 randomized to take 1 teaspoon of psyllium in 8 ounces of liquid daily for 6 weeks or 4 tablespoons a day of the bowel recipe. All subjects received educational information on how dietary choices and fluids can influence constipation. They all kept bowel diaries. Results were calculated using pre- and posttrial scores on a 30-point constipation scoring system, with a higher score indicating more severe constipation.

Constipation was relieved in both groups, with scores declining from 13.9 to 9.0 for the psyllium users and 13.6 to 8.5 for the recipe users during the 6-week trial.

The cost of 6 weeks' worth of the bowel recipe was $8.65, compared with $16.72 for the commercial psyllium product.

The authors concluded that the homemade recipe was “an effective and economical stool-bulking agent for the treatment of constipation.”

Pantry Remedy For Constipation

1 cup applesauce

1 cup coarse, unprocessed wheat bran

1/4 cup prune juice

Source: Dr. Drewes

LOS ANGELES — Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91—nearly a doubling of risk—in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours vs. 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference. Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days. Dizziness, the most common side effect, occurred in about 7% of patients. The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year—on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients. In that pivotal study, 67% patients assigned to placebo experienced migraines.

The consistency of incidence data in the two trials suggests “durability of effect with continued use,” noted Dr. MacGregor and associates in their poster's conclusion.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

LOS ANGELES — Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91—nearly a doubling of risk—in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours vs. 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference. Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days. Dizziness, the most common side effect, occurred in about 7% of patients. The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year—on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients. In that pivotal study, 67% patients assigned to placebo experienced migraines.

The consistency of incidence data in the two trials suggests “durability of effect with continued use,” noted Dr. MacGregor and associates in their poster's conclusion.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

LOS ANGELES — Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91—nearly a doubling of risk—in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours vs. 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference. Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days. Dizziness, the most common side effect, occurred in about 7% of patients. The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year—on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients. In that pivotal study, 67% patients assigned to placebo experienced migraines.

The consistency of incidence data in the two trials suggests “durability of effect with continued use,” noted Dr. MacGregor and associates in their poster's conclusion.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, according to research from the University of Southern California, Los Angeles, that was prsesented at the annual Digestive Disease Week.

Dr. Joaquin Estrada and his associates in the department of surgery at the university reported that those patients who had a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed the charts of 41 patients who were found to have a gangrenous/perforated appendix at surgery.

Dr. Estrada and his colleageus also looked at a total of 116 patients who had been admitted for suspected acute appendicitis but who were not found to have a perforated or gangrenous appendix.

A pathologically normal appendix was found in 13 of the patients in the latter group.

Among those patients with perforation, a total of 23, or 56%, were found to have had an elevated bilirubin upon admission compared with 36, or 31% of those who were not found to have a perforated or gangrenous appendix.

There were several factors that did not distinguish the two groups. These factors included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and patient age.

While larger studies are needed, Dr. Estrada said that these findings may help to assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, Dr Estrada said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, according to research from the University of Southern California, Los Angeles, that was prsesented at the annual Digestive Disease Week.

Dr. Joaquin Estrada and his associates in the department of surgery at the university reported that those patients who had a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed the charts of 41 patients who were found to have a gangrenous/perforated appendix at surgery.

Dr. Estrada and his colleageus also looked at a total of 116 patients who had been admitted for suspected acute appendicitis but who were not found to have a perforated or gangrenous appendix.

A pathologically normal appendix was found in 13 of the patients in the latter group.

Among those patients with perforation, a total of 23, or 56%, were found to have had an elevated bilirubin upon admission compared with 36, or 31% of those who were not found to have a perforated or gangrenous appendix.

There were several factors that did not distinguish the two groups. These factors included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and patient age.

While larger studies are needed, Dr. Estrada said that these findings may help to assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, Dr Estrada said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, according to research from the University of Southern California, Los Angeles, that was prsesented at the annual Digestive Disease Week.

Dr. Joaquin Estrada and his associates in the department of surgery at the university reported that those patients who had a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed the charts of 41 patients who were found to have a gangrenous/perforated appendix at surgery.

Dr. Estrada and his colleageus also looked at a total of 116 patients who had been admitted for suspected acute appendicitis but who were not found to have a perforated or gangrenous appendix.

A pathologically normal appendix was found in 13 of the patients in the latter group.

Among those patients with perforation, a total of 23, or 56%, were found to have had an elevated bilirubin upon admission compared with 36, or 31% of those who were not found to have a perforated or gangrenous appendix.

There were several factors that did not distinguish the two groups. These factors included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and patient age.

While larger studies are needed, Dr. Estrada said that these findings may help to assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, Dr Estrada said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

VANCOUVER, B.C. — Aggression isn't a diagnosis, it's a symptom. It may be secondary to a psychiatric diagnosis, or unrelated. It may be a temporary response to the environment, or deeply woven into a child's personality, said Dr. Susan Lomax at a conference sponsored by the North Pacific Pediatric Society.

You need to know the whys of aggression before you can devise a plan to help. “What is driving the aggression makes a difference with the intervention,” said Dr. Lomax, an adolescent psychiatrist at British Columbia Children's Hospital and a faculty member at the University of British Columbia in Vancouver.

It may be helpful to look at aggression in the context of a child's other traits.

▸ The Aggressive Child. You may see deliberate, proactive, or predatory aggression in an antisocial child. In this context, aggression isn't explosive, but controlled, goal-oriented, and often planned. It's rewarding to the child in some way, perhaps as a release from boredom. This type of aggression is seen when a child methodically injures animals or other children. It is the most difficult form of aggression to treat.

When contemplating a treatment plan, keep in mind that antisocial children want to know “what's in it for me?” Therefore, concrete, reward-based therapy within a highly structured program makes sense.

One-on-one psychotherapy is rarely useful because these children “often don't have the ability to talk through problems internally,” said Dr. Lomax. Group therapy may be more helpful because these children may be sensitive to peer approval or disapproval. Because their aggression may arise from a desire for stimulation, encourage time-consuming, prosocial activities such as organized sports, “where they can reinforce skills … and acquire skills they can feel good about.”

▸ The Anxious Child. In sharp contrast to an antisocial child, aggression in a jittery child erupts as a fear reaction. Blowups in the morning before school represent avoidant behavior. These children may have an anxiety disorder, posttraumatic stress disorder, depression, or, rarely, psychosis. Treatment of the psychosis may reduce the high level of arousal that leads to aggressive behavior, Dr. Lomax said.

▸ The Rigid Child. “These kids want things their way or no way,” she explained. They may become infuriated at having to leave the computer to come to dinner. “They think they're picked on, that there's no justice.”

Rigid children “habitually misinterpret cues” from parents, teachers, and peers. As a result, they fly off the handle in anger.

Associated diagnoses may include: oppositional defiant disorder, the autism spectrum, obsessive-compulsive disorder (when anger arises from interference with rituals), and nonverbal learning disabilities. Their temperaments tend to be inflexible and stubborn.

▸ The Impulsive Child. Frontal lobe dysfunction plays a role in the aggression of a child who becomes very angry very fast and cannot self-calm. Beyond their inability to inhibit their impulses, “these children have a hard time planning or envisioning consequences,” said Dr. Lomax.

Possibly associated diagnoses might include ADHD, fetal alcohol syndrome, brain injury, or substance abuse.

▸ The Dysregulated Child. Irritability, agitation, volatility, and mood instability underlie aggression in dysregulated children. Developmental or genetic issues should be explored. For example, dysregulated aggression is common in children who experienced few nurturing, calming experiences in the first years of life.

Dysregulation may be an early sign of bipolar disorder, even if classic adult signs of euphoria and grandiosity are not present. In children, aggression and sleeplessness may alternate with depression and lethargy in a pattern of rapid cycling.

▸ The Abused or Traumatized Child. Aggressive behaviors in such children make sense within the context of their lives, because the “fight” response to a survival threat naturally requires quick and decisive action.

“Their autonomic system is on overdrive. They become panicked if someone tries to control them,” said Dr. Lomax.

They are hypervigilant, distrustful, and show diminished cognition and a loss of impulse control when they perceive a threat. Seemingly “minor” events may precipitate catastrophic reactions in these children, she said.

▸ Children Whose Lives Are in Flux. It is also important to remember that aggression may be symptomatic of a situational upheaval in a child's life: a parent's divorce, for example, or a serious illness.

Consider, too, the family context in which aggression occurs.

Aggression may be a learned behavior, modeled by parents with their own history of violence and/or Axis I diagnoses.

Be forewarned; parents may take “deep and grievous offense” at the notion that the family dynamic may be a contributor to the child's aggressive behavior. Dr. Lomax suggested a careful assessment of whether they are intellectually capable of insight and stable enough to accept suggestions about how to learn and practice anger management and training in parenting skills such as boundary and limit setting.

Sometimes, it may be necessary to go outside the immediate family for help, to grandparents or spouse equivalents, she said. Psychoeducation, enhancing attachment, marital therapy, and parent support groups are all helpful adjuncts for parents of aggressive children.

“These families are often held hostage to their child's behavior,” she said.

The treatment of a child with impulsive or affective aggression may be successful in one-on-one sessions or in group therapy. Principles include anxiety management, correction of cognitive distortions, assertiveness training, impulse control strategies, stress reduction, and, if applicable, therapy to address trauma.

In extreme cases, medications may be both necessary and helpful.

Treat any primary psychiatric disorder first, then consider risperidone in very low doses (0.5–2 mg/day); a mood stabilizer if the child is irritable and volatile; or a β-blocker in the context of hyperarousal, said Dr. Lomax.

She cautioned that antidepressants can sometimes have activating effects that exacerbate aggression in some children. Lorazepam should be avoided for this reason in aggressive children, and children prescribed other antidepressants should be monitored very closely early in therapy for signs of akathisia, sleep problems, and out-of-character “rage reactions.”

When a Child Is Aggressive, Ask:

▸ When did the behavior start? What was the context? What is the child's age?

▸ Is the child capable of empathy and/or real regret? Does he/she laugh when confronted with the consequences of aggressive behavior?

▸ Is the aggression situation specific?

▸ How is the child's general tolerance for frustration?

▸ Has the child had a traumatic experience? Was he/she nurtured early in life?

▸ Do other children in the family have problems with aggression?

▸ How readily does the child adjust to changes in routine?

Source: Dr. Lomax

VANCOUVER, B.C. — Aggression isn't a diagnosis, it's a symptom. It may be secondary to a psychiatric diagnosis, or unrelated. It may be a temporary response to the environment, or deeply woven into a child's personality, said Dr. Susan Lomax at a conference sponsored by the North Pacific Pediatric Society.

You need to know the whys of aggression before you can devise a plan to help. “What is driving the aggression makes a difference with the intervention,” said Dr. Lomax, an adolescent psychiatrist at British Columbia Children's Hospital and a faculty member at the University of British Columbia in Vancouver.

It may be helpful to look at aggression in the context of a child's other traits.

▸ The Aggressive Child. You may see deliberate, proactive, or predatory aggression in an antisocial child. In this context, aggression isn't explosive, but controlled, goal-oriented, and often planned. It's rewarding to the child in some way, perhaps as a release from boredom. This type of aggression is seen when a child methodically injures animals or other children. It is the most difficult form of aggression to treat.

When contemplating a treatment plan, keep in mind that antisocial children want to know “what's in it for me?” Therefore, concrete, reward-based therapy within a highly structured program makes sense.

One-on-one psychotherapy is rarely useful because these children “often don't have the ability to talk through problems internally,” said Dr. Lomax. Group therapy may be more helpful because these children may be sensitive to peer approval or disapproval. Because their aggression may arise from a desire for stimulation, encourage time-consuming, prosocial activities such as organized sports, “where they can reinforce skills … and acquire skills they can feel good about.”

▸ The Anxious Child. In sharp contrast to an antisocial child, aggression in a jittery child erupts as a fear reaction. Blowups in the morning before school represent avoidant behavior. These children may have an anxiety disorder, posttraumatic stress disorder, depression, or, rarely, psychosis. Treatment of the psychosis may reduce the high level of arousal that leads to aggressive behavior, Dr. Lomax said.

▸ The Rigid Child. “These kids want things their way or no way,” she explained. They may become infuriated at having to leave the computer to come to dinner. “They think they're picked on, that there's no justice.”

Rigid children “habitually misinterpret cues” from parents, teachers, and peers. As a result, they fly off the handle in anger.

Associated diagnoses may include: oppositional defiant disorder, the autism spectrum, obsessive-compulsive disorder (when anger arises from interference with rituals), and nonverbal learning disabilities. Their temperaments tend to be inflexible and stubborn.

▸ The Impulsive Child. Frontal lobe dysfunction plays a role in the aggression of a child who becomes very angry very fast and cannot self-calm. Beyond their inability to inhibit their impulses, “these children have a hard time planning or envisioning consequences,” said Dr. Lomax.

Possibly associated diagnoses might include ADHD, fetal alcohol syndrome, brain injury, or substance abuse.

▸ The Dysregulated Child. Irritability, agitation, volatility, and mood instability underlie aggression in dysregulated children. Developmental or genetic issues should be explored. For example, dysregulated aggression is common in children who experienced few nurturing, calming experiences in the first years of life.

Dysregulation may be an early sign of bipolar disorder, even if classic adult signs of euphoria and grandiosity are not present. In children, aggression and sleeplessness may alternate with depression and lethargy in a pattern of rapid cycling.

▸ The Abused or Traumatized Child. Aggressive behaviors in such children make sense within the context of their lives, because the “fight” response to a survival threat naturally requires quick and decisive action.

“Their autonomic system is on overdrive. They become panicked if someone tries to control them,” said Dr. Lomax.

They are hypervigilant, distrustful, and show diminished cognition and a loss of impulse control when they perceive a threat. Seemingly “minor” events may precipitate catastrophic reactions in these children, she said.

▸ Children Whose Lives Are in Flux. It is also important to remember that aggression may be symptomatic of a situational upheaval in a child's life: a parent's divorce, for example, or a serious illness.

Consider, too, the family context in which aggression occurs.

Aggression may be a learned behavior, modeled by parents with their own history of violence and/or Axis I diagnoses.

Be forewarned; parents may take “deep and grievous offense” at the notion that the family dynamic may be a contributor to the child's aggressive behavior. Dr. Lomax suggested a careful assessment of whether they are intellectually capable of insight and stable enough to accept suggestions about how to learn and practice anger management and training in parenting skills such as boundary and limit setting.

Sometimes, it may be necessary to go outside the immediate family for help, to grandparents or spouse equivalents, she said. Psychoeducation, enhancing attachment, marital therapy, and parent support groups are all helpful adjuncts for parents of aggressive children.

“These families are often held hostage to their child's behavior,” she said.

The treatment of a child with impulsive or affective aggression may be successful in one-on-one sessions or in group therapy. Principles include anxiety management, correction of cognitive distortions, assertiveness training, impulse control strategies, stress reduction, and, if applicable, therapy to address trauma.

In extreme cases, medications may be both necessary and helpful.

Treat any primary psychiatric disorder first, then consider risperidone in very low doses (0.5–2 mg/day); a mood stabilizer if the child is irritable and volatile; or a β-blocker in the context of hyperarousal, said Dr. Lomax.

She cautioned that antidepressants can sometimes have activating effects that exacerbate aggression in some children. Lorazepam should be avoided for this reason in aggressive children, and children prescribed other antidepressants should be monitored very closely early in therapy for signs of akathisia, sleep problems, and out-of-character “rage reactions.”

When a Child Is Aggressive, Ask:

▸ When did the behavior start? What was the context? What is the child's age?

▸ Is the child capable of empathy and/or real regret? Does he/she laugh when confronted with the consequences of aggressive behavior?

▸ Is the aggression situation specific?

▸ How is the child's general tolerance for frustration?

▸ Has the child had a traumatic experience? Was he/she nurtured early in life?

▸ Do other children in the family have problems with aggression?

▸ How readily does the child adjust to changes in routine?

Source: Dr. Lomax

VANCOUVER, B.C. — Aggression isn't a diagnosis, it's a symptom. It may be secondary to a psychiatric diagnosis, or unrelated. It may be a temporary response to the environment, or deeply woven into a child's personality, said Dr. Susan Lomax at a conference sponsored by the North Pacific Pediatric Society.

You need to know the whys of aggression before you can devise a plan to help. “What is driving the aggression makes a difference with the intervention,” said Dr. Lomax, an adolescent psychiatrist at British Columbia Children's Hospital and a faculty member at the University of British Columbia in Vancouver.

It may be helpful to look at aggression in the context of a child's other traits.

▸ The Aggressive Child. You may see deliberate, proactive, or predatory aggression in an antisocial child. In this context, aggression isn't explosive, but controlled, goal-oriented, and often planned. It's rewarding to the child in some way, perhaps as a release from boredom. This type of aggression is seen when a child methodically injures animals or other children. It is the most difficult form of aggression to treat.

When contemplating a treatment plan, keep in mind that antisocial children want to know “what's in it for me?” Therefore, concrete, reward-based therapy within a highly structured program makes sense.

One-on-one psychotherapy is rarely useful because these children “often don't have the ability to talk through problems internally,” said Dr. Lomax. Group therapy may be more helpful because these children may be sensitive to peer approval or disapproval. Because their aggression may arise from a desire for stimulation, encourage time-consuming, prosocial activities such as organized sports, “where they can reinforce skills … and acquire skills they can feel good about.”

▸ The Anxious Child. In sharp contrast to an antisocial child, aggression in a jittery child erupts as a fear reaction. Blowups in the morning before school represent avoidant behavior. These children may have an anxiety disorder, posttraumatic stress disorder, depression, or, rarely, psychosis. Treatment of the psychosis may reduce the high level of arousal that leads to aggressive behavior, Dr. Lomax said.

▸ The Rigid Child. “These kids want things their way or no way,” she explained. They may become infuriated at having to leave the computer to come to dinner. “They think they're picked on, that there's no justice.”

Rigid children “habitually misinterpret cues” from parents, teachers, and peers. As a result, they fly off the handle in anger.

Associated diagnoses may include: oppositional defiant disorder, the autism spectrum, obsessive-compulsive disorder (when anger arises from interference with rituals), and nonverbal learning disabilities. Their temperaments tend to be inflexible and stubborn.

▸ The Impulsive Child. Frontal lobe dysfunction plays a role in the aggression of a child who becomes very angry very fast and cannot self-calm. Beyond their inability to inhibit their impulses, “these children have a hard time planning or envisioning consequences,” said Dr. Lomax.

Possibly associated diagnoses might include ADHD, fetal alcohol syndrome, brain injury, or substance abuse.

▸ The Dysregulated Child. Irritability, agitation, volatility, and mood instability underlie aggression in dysregulated children. Developmental or genetic issues should be explored. For example, dysregulated aggression is common in children who experienced few nurturing, calming experiences in the first years of life.

Dysregulation may be an early sign of bipolar disorder, even if classic adult signs of euphoria and grandiosity are not present. In children, aggression and sleeplessness may alternate with depression and lethargy in a pattern of rapid cycling.

▸ The Abused or Traumatized Child. Aggressive behaviors in such children make sense within the context of their lives, because the “fight” response to a survival threat naturally requires quick and decisive action.

“Their autonomic system is on overdrive. They become panicked if someone tries to control them,” said Dr. Lomax.

They are hypervigilant, distrustful, and show diminished cognition and a loss of impulse control when they perceive a threat. Seemingly “minor” events may precipitate catastrophic reactions in these children, she said.

▸ Children Whose Lives Are in Flux. It is also important to remember that aggression may be symptomatic of a situational upheaval in a child's life: a parent's divorce, for example, or a serious illness.

Consider, too, the family context in which aggression occurs.

Aggression may be a learned behavior, modeled by parents with their own history of violence and/or Axis I diagnoses.

Be forewarned; parents may take “deep and grievous offense” at the notion that the family dynamic may be a contributor to the child's aggressive behavior. Dr. Lomax suggested a careful assessment of whether they are intellectually capable of insight and stable enough to accept suggestions about how to learn and practice anger management and training in parenting skills such as boundary and limit setting.

Sometimes, it may be necessary to go outside the immediate family for help, to grandparents or spouse equivalents, she said. Psychoeducation, enhancing attachment, marital therapy, and parent support groups are all helpful adjuncts for parents of aggressive children.

“These families are often held hostage to their child's behavior,” she said.

The treatment of a child with impulsive or affective aggression may be successful in one-on-one sessions or in group therapy. Principles include anxiety management, correction of cognitive distortions, assertiveness training, impulse control strategies, stress reduction, and, if applicable, therapy to address trauma.

In extreme cases, medications may be both necessary and helpful.

Treat any primary psychiatric disorder first, then consider risperidone in very low doses (0.5–2 mg/day); a mood stabilizer if the child is irritable and volatile; or a β-blocker in the context of hyperarousal, said Dr. Lomax.

She cautioned that antidepressants can sometimes have activating effects that exacerbate aggression in some children. Lorazepam should be avoided for this reason in aggressive children, and children prescribed other antidepressants should be monitored very closely early in therapy for signs of akathisia, sleep problems, and out-of-character “rage reactions.”

When a Child Is Aggressive, Ask:

▸ When did the behavior start? What was the context? What is the child's age?

▸ Is the child capable of empathy and/or real regret? Does he/she laugh when confronted with the consequences of aggressive behavior?

▸ Is the aggression situation specific?

▸ How is the child's general tolerance for frustration?

▸ Has the child had a traumatic experience? Was he/she nurtured early in life?

▸ Do other children in the family have problems with aggression?

▸ How readily does the child adjust to changes in routine?

Source: Dr. Lomax