Betsy Bates

PALM SPRINGS, CALIF. — Patients with low back pain who experience significant improvement in pain and function after one set of botulinum toxin type A injections are highly likely to respond to subsequent treatments, Bahman Jabbari, M.D., reported at the annual meeting of the American Academy of Pain Medicine.

Those who do not obtain relief within about 2 weeks of an initial series of injections are significantly less likely to respond to subsequent treatments, said Dr. Jabbari, professor of neurology at Yale University, New Haven.

A prospective study of 75 adults with chronic, refractory low back pain was undertaken by Dr. Jabbari and his associates at Walter Reed Army Medical Center, Washington.

Botulinum toxin type A (Botox, 100 U/cc) was injected into paraspinal muscles at three to five horizontal levels (50 U/site) on each side as close as possible to the tender points, said Dr. Jabbari, who presented the data in poster form. The mean dose per session was 285 U, with a range of 200–450 U, depending on the patient extension and laterality.

Patients received neurologic examinations and were administered a visual analog pain assessment, Oswestry Low Back Pain Questionnaire, and the Pain Impact Questionnaire at baseline, 3 weeks, and 2, 4, 6, 8, 10, 12, and 14 months after the initial treatment. They could request subsequent Botox injections when pain recurred, usually at 4, 8, and 12 months. Pain medications and physical therapy were not adjusted during the study.

Significant pain relief and improvement in function were noted by 42 of 75 patients at 3 weeks and 40 of 75 patients at 2 months. Of these patients, 90% continued to respond to subsequent treatments. Those who did not obtain initial relief were unlikely to respond during future treatments.

No serious adverse events were reported. Two patients experienced a transient flu-like reaction, and another described acute root pain for 60 seconds after being injected.

Age, pain intensity, pain duration, laterality, and a history of previous surgery all failed to correlate with whether a patient responded or failed to improve with Botox.

He noted that patients who respond generally begin to notice improvement within 3–4 days of an initial injection session. Relief typically peaks at about 10 days to 2 weeks and generally lasts about 4 months.

Allergan Inc. provided funding for the study.

PALM SPRINGS, CALIF. — Patients with low back pain who experience significant improvement in pain and function after one set of botulinum toxin type A injections are highly likely to respond to subsequent treatments, Bahman Jabbari, M.D., reported at the annual meeting of the American Academy of Pain Medicine.

Those who do not obtain relief within about 2 weeks of an initial series of injections are significantly less likely to respond to subsequent treatments, said Dr. Jabbari, professor of neurology at Yale University, New Haven.

A prospective study of 75 adults with chronic, refractory low back pain was undertaken by Dr. Jabbari and his associates at Walter Reed Army Medical Center, Washington.

Botulinum toxin type A (Botox, 100 U/cc) was injected into paraspinal muscles at three to five horizontal levels (50 U/site) on each side as close as possible to the tender points, said Dr. Jabbari, who presented the data in poster form. The mean dose per session was 285 U, with a range of 200–450 U, depending on the patient extension and laterality.

Patients received neurologic examinations and were administered a visual analog pain assessment, Oswestry Low Back Pain Questionnaire, and the Pain Impact Questionnaire at baseline, 3 weeks, and 2, 4, 6, 8, 10, 12, and 14 months after the initial treatment. They could request subsequent Botox injections when pain recurred, usually at 4, 8, and 12 months. Pain medications and physical therapy were not adjusted during the study.

Significant pain relief and improvement in function were noted by 42 of 75 patients at 3 weeks and 40 of 75 patients at 2 months. Of these patients, 90% continued to respond to subsequent treatments. Those who did not obtain initial relief were unlikely to respond during future treatments.

No serious adverse events were reported. Two patients experienced a transient flu-like reaction, and another described acute root pain for 60 seconds after being injected.

Age, pain intensity, pain duration, laterality, and a history of previous surgery all failed to correlate with whether a patient responded or failed to improve with Botox.

He noted that patients who respond generally begin to notice improvement within 3–4 days of an initial injection session. Relief typically peaks at about 10 days to 2 weeks and generally lasts about 4 months.

Allergan Inc. provided funding for the study.

PALM SPRINGS, CALIF. — Patients with low back pain who experience significant improvement in pain and function after one set of botulinum toxin type A injections are highly likely to respond to subsequent treatments, Bahman Jabbari, M.D., reported at the annual meeting of the American Academy of Pain Medicine.

Those who do not obtain relief within about 2 weeks of an initial series of injections are significantly less likely to respond to subsequent treatments, said Dr. Jabbari, professor of neurology at Yale University, New Haven.

A prospective study of 75 adults with chronic, refractory low back pain was undertaken by Dr. Jabbari and his associates at Walter Reed Army Medical Center, Washington.

Botulinum toxin type A (Botox, 100 U/cc) was injected into paraspinal muscles at three to five horizontal levels (50 U/site) on each side as close as possible to the tender points, said Dr. Jabbari, who presented the data in poster form. The mean dose per session was 285 U, with a range of 200–450 U, depending on the patient extension and laterality.

Patients received neurologic examinations and were administered a visual analog pain assessment, Oswestry Low Back Pain Questionnaire, and the Pain Impact Questionnaire at baseline, 3 weeks, and 2, 4, 6, 8, 10, 12, and 14 months after the initial treatment. They could request subsequent Botox injections when pain recurred, usually at 4, 8, and 12 months. Pain medications and physical therapy were not adjusted during the study.

Significant pain relief and improvement in function were noted by 42 of 75 patients at 3 weeks and 40 of 75 patients at 2 months. Of these patients, 90% continued to respond to subsequent treatments. Those who did not obtain initial relief were unlikely to respond during future treatments.

No serious adverse events were reported. Two patients experienced a transient flu-like reaction, and another described acute root pain for 60 seconds after being injected.

Age, pain intensity, pain duration, laterality, and a history of previous surgery all failed to correlate with whether a patient responded or failed to improve with Botox.

He noted that patients who respond generally begin to notice improvement within 3–4 days of an initial injection session. Relief typically peaks at about 10 days to 2 weeks and generally lasts about 4 months.

Allergan Inc. provided funding for the study.

LOS ANGELES — Physicians were the least likely among health care workers to comply with hospital rules requiring isolation gowns in rooms of patients carrying multiresistant organisms, according to a study exploring ways to reduce severe nosocomial infection outbreaks.

Among physicians, surgeons were the least compliant, reported Farrin A. Manian, M.D., an infectious disease specialist at St. John's Mercy Medical Center in St. Louis, at the annual meeting of the Society for Healthcare Epidemiology of America.

Gowns and gloves are required as part of modified contact precautions (MCP) at Dr. Manian's hospital in an effort to avert the epidemic spread of infections caused by organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile.

All visitors and health care workers must comply with precautions before entering the well-marked rooms of patients infected or colonized by these pathogens.

But just 74% of 2,144 people seen entering MCP rooms wore gowns in a covert observation study coordinated by Dr. Manian and John J. Ponzillo, Pharm.D., at the 900-bed tertiary care medical center.

Health care workers were more likely than visitors to wear gowns, at rates of 77% and 66%, respectively. The health care workers most likely to comply were respiratory therapists, with a compliance rate of 96%. Physicians were the worst at following infection control gown orders, with a compliance rate just over 67%.

Compliance also varied by medical specialty, with intensivists topping the list at a compliance rate of 84%, followed by house staff, 71%, miscellaneous physicians, 70%, internists and family physicians, 61%, and surgeons, 41%.

Logistic regression analysis identified three factors independently associated with noncompliance with the gown rule: location of the patient room in a non-ICU ward, occupation (physician), and male gender. There was a very strong correlation between gown use and glove use among health care workers in the ICU, with 110 of 115 workers (96%) wearing gowns also wearing gloves, compared with 3 of 18 (17%) not wearing gowns.

Dr. Manian stressed the importance of complying with modified isolation precautions in hospital environments increasingly under threat of difficult-to-control nosocomial infections. In an interview about poor physician compliance, he said, “Honestly, I think it has to do with the perception of risk. If I said this patient has Ebola, physicians would comply.”

Some physicians, he added, “think rules don't apply to them.”

Source: Dr. Singh

LOS ANGELES — Physicians were the least likely among health care workers to comply with hospital rules requiring isolation gowns in rooms of patients carrying multiresistant organisms, according to a study exploring ways to reduce severe nosocomial infection outbreaks.

Among physicians, surgeons were the least compliant, reported Farrin A. Manian, M.D., an infectious disease specialist at St. John's Mercy Medical Center in St. Louis, at the annual meeting of the Society for Healthcare Epidemiology of America.

Gowns and gloves are required as part of modified contact precautions (MCP) at Dr. Manian's hospital in an effort to avert the epidemic spread of infections caused by organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile.

All visitors and health care workers must comply with precautions before entering the well-marked rooms of patients infected or colonized by these pathogens.

But just 74% of 2,144 people seen entering MCP rooms wore gowns in a covert observation study coordinated by Dr. Manian and John J. Ponzillo, Pharm.D., at the 900-bed tertiary care medical center.

Health care workers were more likely than visitors to wear gowns, at rates of 77% and 66%, respectively. The health care workers most likely to comply were respiratory therapists, with a compliance rate of 96%. Physicians were the worst at following infection control gown orders, with a compliance rate just over 67%.

Compliance also varied by medical specialty, with intensivists topping the list at a compliance rate of 84%, followed by house staff, 71%, miscellaneous physicians, 70%, internists and family physicians, 61%, and surgeons, 41%.

Logistic regression analysis identified three factors independently associated with noncompliance with the gown rule: location of the patient room in a non-ICU ward, occupation (physician), and male gender. There was a very strong correlation between gown use and glove use among health care workers in the ICU, with 110 of 115 workers (96%) wearing gowns also wearing gloves, compared with 3 of 18 (17%) not wearing gowns.

Dr. Manian stressed the importance of complying with modified isolation precautions in hospital environments increasingly under threat of difficult-to-control nosocomial infections. In an interview about poor physician compliance, he said, “Honestly, I think it has to do with the perception of risk. If I said this patient has Ebola, physicians would comply.”

Some physicians, he added, “think rules don't apply to them.”

Source: Dr. Singh

LOS ANGELES — Physicians were the least likely among health care workers to comply with hospital rules requiring isolation gowns in rooms of patients carrying multiresistant organisms, according to a study exploring ways to reduce severe nosocomial infection outbreaks.

Among physicians, surgeons were the least compliant, reported Farrin A. Manian, M.D., an infectious disease specialist at St. John's Mercy Medical Center in St. Louis, at the annual meeting of the Society for Healthcare Epidemiology of America.

Gowns and gloves are required as part of modified contact precautions (MCP) at Dr. Manian's hospital in an effort to avert the epidemic spread of infections caused by organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile.

All visitors and health care workers must comply with precautions before entering the well-marked rooms of patients infected or colonized by these pathogens.

But just 74% of 2,144 people seen entering MCP rooms wore gowns in a covert observation study coordinated by Dr. Manian and John J. Ponzillo, Pharm.D., at the 900-bed tertiary care medical center.

Health care workers were more likely than visitors to wear gowns, at rates of 77% and 66%, respectively. The health care workers most likely to comply were respiratory therapists, with a compliance rate of 96%. Physicians were the worst at following infection control gown orders, with a compliance rate just over 67%.

Compliance also varied by medical specialty, with intensivists topping the list at a compliance rate of 84%, followed by house staff, 71%, miscellaneous physicians, 70%, internists and family physicians, 61%, and surgeons, 41%.

Logistic regression analysis identified three factors independently associated with noncompliance with the gown rule: location of the patient room in a non-ICU ward, occupation (physician), and male gender. There was a very strong correlation between gown use and glove use among health care workers in the ICU, with 110 of 115 workers (96%) wearing gowns also wearing gloves, compared with 3 of 18 (17%) not wearing gowns.

Dr. Manian stressed the importance of complying with modified isolation precautions in hospital environments increasingly under threat of difficult-to-control nosocomial infections. In an interview about poor physician compliance, he said, “Honestly, I think it has to do with the perception of risk. If I said this patient has Ebola, physicians would comply.”

Some physicians, he added, “think rules don't apply to them.”

Source: Dr. Singh

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Analysis of samples obtained at various time intervals revealed that both VRE and MRSA survived 24 hours, while PSAE was less hardy, growing for 5 minutes on keyboard covers and 1 hour on keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the keyboards. For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the keyboard. Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), used as directed with a 5-minute dwell time, disinfected keyboards but failed to eliminate VRE and PSAE on keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers. It is unknown how keyboards and keyboard covers should be disinfected, since there's “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting. “On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for healthcare workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Analysis of samples obtained at various time intervals revealed that both VRE and MRSA survived 24 hours, while PSAE was less hardy, growing for 5 minutes on keyboard covers and 1 hour on keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the keyboards. For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the keyboard. Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), used as directed with a 5-minute dwell time, disinfected keyboards but failed to eliminate VRE and PSAE on keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers. It is unknown how keyboards and keyboard covers should be disinfected, since there's “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting. “On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for healthcare workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

LOS ANGELES — Computer keyboards and keyboard covers harbored vancomycin-resistant Enterococcus faecium and methicillin-resistant Staphylococcus aureus for more than 24 hours, during which time the bacteria easily spread to bare, and in some cases, gloved hands, a Northwestern University study has found.

The findings strongly suggest the need for health care providers to wash their hands after using computers, particularly in hospital settings and around immunocompromised patients, said Gary A. Noskin, M.D., an infectious disease specialist at Northwestern University and director of health care epidemiology and quality at Northwestern Memorial Hospital in Chicago.

Electronic patient records have ushered more computers into examining and patient rooms, heightening the importance of their role as a “viable reservoir for pathogenic bacteria,” in the words of the study presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

Investigators inoculated standard computer keyboards and Dell computer keyboard covers with isolates of vancomycin-resistant E. faecium (VRE), methicillin-resistant S. aureus (MRSA), and Pseudomonas aeruginosa (PSAE).

Analysis of samples obtained at various time intervals revealed that both VRE and MRSA survived 24 hours, while PSAE was less hardy, growing for 5 minutes on keyboard covers and 1 hour on keyboards.

Bacteria transmission to volunteers' hands increased with the number of times they touched the keyboards. For example, MRSA resulted in recovery of bacteria on hands 92% of the time with 5 touches, versus 42% of the time after 1 touch of the keyboard. Rates for VRE were 50% and 22% after 5 touches and 1 touch, and with PSAE, 18% and 9%, respectively.

Bare hands were more likely than were gloved hands to acquire VRE and MRSA, 67% versus 7%, and 80% versus 67%, respectively.

Investigators then conducted an experiment to see whether two quaternary ammonium-based germicides commonly used in health care settings could eliminate bacterial contamination on keyboards and keyboard covers.

Virex II 256 (Johnson Wax Professional, Sturtevant, Wisc.), when used as directed with a 10-minute dwell time, successfully disinfected both keyboards and keyboard covers.

Sani-Wipes (PDI, Upper Saddle River, N.J.), used as directed with a 5-minute dwell time, disinfected keyboards but failed to eliminate VRE and PSAE on keyboard covers.

Dr. Noskin and his associates recommended hand washing after contact with computers. It is unknown how keyboards and keyboard covers should be disinfected, since there's “just no data” on how frequent germicide use might impact their durability, circuitry, and electronics, he said in a telephone interview following the meeting. “On a practical level, keyboards and other environmental surfaces are never going to be sterile, so it's just very important for healthcare workers to wash their hands so the contamination is less relevant,” he said.

No industry funding was used for the study.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

FLORENCE, ITALY — Terbinafine can cure onychomycosis in patients who take it for only 1 week every 2–3 months for up to a year, Martin N. Zaias, M.D., reported at 13th Congress of the European Academy of Dermatology and Venereology.

“From an economic point of view, our concern was that if a patient is taking a daily dose for 3 months, the cost is obviously going to be greater than taking a daily dose just 1 week of every 2 or 3 months,” said Dr. Zaias, in private practice in Miami.

He noted that earlier studies by his group confirmed that terbinafine (Lamisil) remains in the nail bed for at least a month after being taken for 7 consecutive days at a 250-mg/day dosage.

Pulse dosing using a 1-week-per-month schedule became an accepted way to treat Trichophyton rubrum onychomycosis.

The current study was aimed at seeing how far that limit could be stretched.

“If 1 week out of the month worked, why not 1 week out of every 2 months … or 3 months … or 4?” he asked.

Nine of 10 patients recruited from Dr. Zaias's practice were cured within a year after taking the medication for 1 week every 2 months at the standard dosage of 250 mg/day. Twelve of 12 patients were cured taking terbinafine for 1 week every 3 months.

When the 1-week pulse was extended to every 4 months, however, the cure rate dropped to 10 of 17 patients tested.

The researchers monitored patients' progress by measuring the extent of involvement on the nail bed from a scalpel nick placed at the onset of the trial.

FLORENCE, ITALY — Terbinafine can cure onychomycosis in patients who take it for only 1 week every 2–3 months for up to a year, Martin N. Zaias, M.D., reported at 13th Congress of the European Academy of Dermatology and Venereology.

“From an economic point of view, our concern was that if a patient is taking a daily dose for 3 months, the cost is obviously going to be greater than taking a daily dose just 1 week of every 2 or 3 months,” said Dr. Zaias, in private practice in Miami.

He noted that earlier studies by his group confirmed that terbinafine (Lamisil) remains in the nail bed for at least a month after being taken for 7 consecutive days at a 250-mg/day dosage.

Pulse dosing using a 1-week-per-month schedule became an accepted way to treat Trichophyton rubrum onychomycosis.

The current study was aimed at seeing how far that limit could be stretched.

“If 1 week out of the month worked, why not 1 week out of every 2 months … or 3 months … or 4?” he asked.

Nine of 10 patients recruited from Dr. Zaias's practice were cured within a year after taking the medication for 1 week every 2 months at the standard dosage of 250 mg/day. Twelve of 12 patients were cured taking terbinafine for 1 week every 3 months.

When the 1-week pulse was extended to every 4 months, however, the cure rate dropped to 10 of 17 patients tested.

The researchers monitored patients' progress by measuring the extent of involvement on the nail bed from a scalpel nick placed at the onset of the trial.

FLORENCE, ITALY — Terbinafine can cure onychomycosis in patients who take it for only 1 week every 2–3 months for up to a year, Martin N. Zaias, M.D., reported at 13th Congress of the European Academy of Dermatology and Venereology.

“From an economic point of view, our concern was that if a patient is taking a daily dose for 3 months, the cost is obviously going to be greater than taking a daily dose just 1 week of every 2 or 3 months,” said Dr. Zaias, in private practice in Miami.

He noted that earlier studies by his group confirmed that terbinafine (Lamisil) remains in the nail bed for at least a month after being taken for 7 consecutive days at a 250-mg/day dosage.

Pulse dosing using a 1-week-per-month schedule became an accepted way to treat Trichophyton rubrum onychomycosis.

The current study was aimed at seeing how far that limit could be stretched.

“If 1 week out of the month worked, why not 1 week out of every 2 months … or 3 months … or 4?” he asked.

Nine of 10 patients recruited from Dr. Zaias's practice were cured within a year after taking the medication for 1 week every 2 months at the standard dosage of 250 mg/day. Twelve of 12 patients were cured taking terbinafine for 1 week every 3 months.

When the 1-week pulse was extended to every 4 months, however, the cure rate dropped to 10 of 17 patients tested.

The researchers monitored patients' progress by measuring the extent of involvement on the nail bed from a scalpel nick placed at the onset of the trial.

PALM SPRINGS, CALIF. – Physicians who doubt that chronic pain patients need and deserve cognitive-behavioral therapy as an adjunct to other treatments need to take an honest look at how well modern medicine treats pain, Dennis C. Turk, Ph.D., said at the annual meeting of the American Academy of Pain Medicine.

Opioids reduce severe, chronic pain by only about a third. Moreover, up to 50% of patients discontinue opioid therapy because of a lack of efficacy or because of side effects.

At the end of interventional pain trials, the vast majority of patients have improved so little they would still qualify for a new trial. Even surgical procedures that sever neurologic pathways believed to be responsible for a patient's pain often fail to alleviate the symptoms.

“Our best efforts still by and large don't cure people,” said Dr. Turk, professor of anesthesiology at the University of Washington, Seattle.

Pain is real, but it is a subjective perception “resulting from the transduction, transmission, and modulation of sensory input filtered through a person's genetic composition and prior learning history and modulated further by [the person's] current physiological status, idiosyncratic appraisals, expectations, current mood state, and sociocultural environment,” he said. In other words, “that arm or neck or shoulder is attached to a human being with a social context and with a history.”

Underlying physical pain are emotional responses: fear, uncertainty, demoralization, and worry about the future. A family is involved, suffering as well.

Offering or referring patients for cognitive-behavioral therapy (CBT) acknowledges that pain may not be curable in every patient and that life must go on around it. It also gives patients credit for being capable of actively processing information and learning adaptive ways of thinking, feeling, and behaving, Dr. Turk said.

The exact CBT technique used is less important than the characteristics of the approach in general, according to Dr. Turk. All CBT should be:

▸ Problem oriented.

▸ Time limited.

▸ Educational.

▸ Collaborative (between patient and provider, perhaps family members as well).

▸ Practical, using clinic and home exercises to consolidate skills and identify problem areas.

▸ Anticipatory of setbacks and lapses and able to teach patients to deal with these.

In the context of pain, CBT can be particularly effective in helping patients reconceptualize their problems, making seemingly overwhelming hurdles become manageable.

It can help patients to believe they have the skills necessary to solve problems, transforming them from being passive and helpless to being “active, resourceful, competent,” Dr. Turk said.

By utilizing real examples in a patient's life, CBT can help individuals recognize unhelpful thinking patterns such as overgeneralization, catastrophizing, seeing things in all-or-none terms, jumping to conclusions, selectively focusing on details rather than the big picture, and mind-reading the thoughts of others.

A CBT therapist then helps a patient learn to recognize problems associated with a life of pain and then propose his or her own adaptive solutions. Examples might include feeling bored and restless because of diminished activities, experiencing disharmony in family members due to altered roles, or suffering diminished self-esteem when a patient in chronic pain can no longer work.

A good CBT therapist guides the patient to set realistic solutions approached with step-by-step goals, practiced in sessions and during homework sessions tracked with diaries and charts.

Dr. Turk said he makes success highly attainable from session to session. For example, if increased mobility is a goal and the patient already believes he can walk 1 block, he sets the bar at walking 8/10 of a block every few days for the first week.

Monitoring, reinforcement, listening, and adapting to changing realities are all key to CBT success. Perhaps most important is the anticipation of nonadherence. Right from the start, a therapist can tell patients to expect flare-ups in pain and “slip-ups” in behavior, and a plan can be devised to deal with those situations before they occur.

To illustrate how CBT can work, Dr. Turk recounted the case of an elderly woman with chronic neck pain so severe that her husband retired from his job to care for her. During CBT she identified inactivity as a problem and set a goal of beginning to cook again. A plan was established for her to prepare one meal a day.

During her next visit, the patient's checklist revealed that she had not kept her goal. It seems her husband became nervous when she would begin to cook, telling her she should rest because she “didn't look too good.” He would then prepare the meal.

In this case, moving forward with the CBT plan first required a “husbandectomy,” in which the husband was encouraged to attend some activities at a nearby senior center so that his wife could begin to regain her self-esteem and meet her self-defined goals.

The 10 Rules of CBT Adherence

1. Anticipate nonadherence.

2. Consider the prescribed regimen from the patient's perspective.

3. Foster a collaborative relationship based on negotiation.

4. Prepare for flare-ups.

5. Customize treatment.

6. Enlist family support.

7. Provide a system of continuity and accessibility.

8. Make use of other health care providers (such as occupational or physical therapists) as well as community resources.

9. Repeat, repeat, repeat everything.

10. Don't give up! Pain specialists represent Ellis Island or Lourdes to chronic pain patients. If they were easy patients, “they wouldn't be seeing you.”

Source: Dr. Turk

PALM SPRINGS, CALIF. – Physicians who doubt that chronic pain patients need and deserve cognitive-behavioral therapy as an adjunct to other treatments need to take an honest look at how well modern medicine treats pain, Dennis C. Turk, Ph.D., said at the annual meeting of the American Academy of Pain Medicine.

Opioids reduce severe, chronic pain by only about a third. Moreover, up to 50% of patients discontinue opioid therapy because of a lack of efficacy or because of side effects.

At the end of interventional pain trials, the vast majority of patients have improved so little they would still qualify for a new trial. Even surgical procedures that sever neurologic pathways believed to be responsible for a patient's pain often fail to alleviate the symptoms.

“Our best efforts still by and large don't cure people,” said Dr. Turk, professor of anesthesiology at the University of Washington, Seattle.

Pain is real, but it is a subjective perception “resulting from the transduction, transmission, and modulation of sensory input filtered through a person's genetic composition and prior learning history and modulated further by [the person's] current physiological status, idiosyncratic appraisals, expectations, current mood state, and sociocultural environment,” he said. In other words, “that arm or neck or shoulder is attached to a human being with a social context and with a history.”

Underlying physical pain are emotional responses: fear, uncertainty, demoralization, and worry about the future. A family is involved, suffering as well.

Offering or referring patients for cognitive-behavioral therapy (CBT) acknowledges that pain may not be curable in every patient and that life must go on around it. It also gives patients credit for being capable of actively processing information and learning adaptive ways of thinking, feeling, and behaving, Dr. Turk said.

The exact CBT technique used is less important than the characteristics of the approach in general, according to Dr. Turk. All CBT should be:

▸ Problem oriented.

▸ Time limited.

▸ Educational.

▸ Collaborative (between patient and provider, perhaps family members as well).

▸ Practical, using clinic and home exercises to consolidate skills and identify problem areas.

▸ Anticipatory of setbacks and lapses and able to teach patients to deal with these.

In the context of pain, CBT can be particularly effective in helping patients reconceptualize their problems, making seemingly overwhelming hurdles become manageable.

It can help patients to believe they have the skills necessary to solve problems, transforming them from being passive and helpless to being “active, resourceful, competent,” Dr. Turk said.

By utilizing real examples in a patient's life, CBT can help individuals recognize unhelpful thinking patterns such as overgeneralization, catastrophizing, seeing things in all-or-none terms, jumping to conclusions, selectively focusing on details rather than the big picture, and mind-reading the thoughts of others.

A CBT therapist then helps a patient learn to recognize problems associated with a life of pain and then propose his or her own adaptive solutions. Examples might include feeling bored and restless because of diminished activities, experiencing disharmony in family members due to altered roles, or suffering diminished self-esteem when a patient in chronic pain can no longer work.

A good CBT therapist guides the patient to set realistic solutions approached with step-by-step goals, practiced in sessions and during homework sessions tracked with diaries and charts.

Dr. Turk said he makes success highly attainable from session to session. For example, if increased mobility is a goal and the patient already believes he can walk 1 block, he sets the bar at walking 8/10 of a block every few days for the first week.

Monitoring, reinforcement, listening, and adapting to changing realities are all key to CBT success. Perhaps most important is the anticipation of nonadherence. Right from the start, a therapist can tell patients to expect flare-ups in pain and “slip-ups” in behavior, and a plan can be devised to deal with those situations before they occur.

To illustrate how CBT can work, Dr. Turk recounted the case of an elderly woman with chronic neck pain so severe that her husband retired from his job to care for her. During CBT she identified inactivity as a problem and set a goal of beginning to cook again. A plan was established for her to prepare one meal a day.

During her next visit, the patient's checklist revealed that she had not kept her goal. It seems her husband became nervous when she would begin to cook, telling her she should rest because she “didn't look too good.” He would then prepare the meal.

In this case, moving forward with the CBT plan first required a “husbandectomy,” in which the husband was encouraged to attend some activities at a nearby senior center so that his wife could begin to regain her self-esteem and meet her self-defined goals.

The 10 Rules of CBT Adherence

1. Anticipate nonadherence.

2. Consider the prescribed regimen from the patient's perspective.

3. Foster a collaborative relationship based on negotiation.

4. Prepare for flare-ups.

5. Customize treatment.

6. Enlist family support.

7. Provide a system of continuity and accessibility.

8. Make use of other health care providers (such as occupational or physical therapists) as well as community resources.

9. Repeat, repeat, repeat everything.

10. Don't give up! Pain specialists represent Ellis Island or Lourdes to chronic pain patients. If they were easy patients, “they wouldn't be seeing you.”

Source: Dr. Turk

PALM SPRINGS, CALIF. – Physicians who doubt that chronic pain patients need and deserve cognitive-behavioral therapy as an adjunct to other treatments need to take an honest look at how well modern medicine treats pain, Dennis C. Turk, Ph.D., said at the annual meeting of the American Academy of Pain Medicine.

Opioids reduce severe, chronic pain by only about a third. Moreover, up to 50% of patients discontinue opioid therapy because of a lack of efficacy or because of side effects.

At the end of interventional pain trials, the vast majority of patients have improved so little they would still qualify for a new trial. Even surgical procedures that sever neurologic pathways believed to be responsible for a patient's pain often fail to alleviate the symptoms.

“Our best efforts still by and large don't cure people,” said Dr. Turk, professor of anesthesiology at the University of Washington, Seattle.

Pain is real, but it is a subjective perception “resulting from the transduction, transmission, and modulation of sensory input filtered through a person's genetic composition and prior learning history and modulated further by [the person's] current physiological status, idiosyncratic appraisals, expectations, current mood state, and sociocultural environment,” he said. In other words, “that arm or neck or shoulder is attached to a human being with a social context and with a history.”

Underlying physical pain are emotional responses: fear, uncertainty, demoralization, and worry about the future. A family is involved, suffering as well.

Offering or referring patients for cognitive-behavioral therapy (CBT) acknowledges that pain may not be curable in every patient and that life must go on around it. It also gives patients credit for being capable of actively processing information and learning adaptive ways of thinking, feeling, and behaving, Dr. Turk said.

The exact CBT technique used is less important than the characteristics of the approach in general, according to Dr. Turk. All CBT should be:

▸ Problem oriented.

▸ Time limited.

▸ Educational.

▸ Collaborative (between patient and provider, perhaps family members as well).

▸ Practical, using clinic and home exercises to consolidate skills and identify problem areas.

▸ Anticipatory of setbacks and lapses and able to teach patients to deal with these.

In the context of pain, CBT can be particularly effective in helping patients reconceptualize their problems, making seemingly overwhelming hurdles become manageable.

It can help patients to believe they have the skills necessary to solve problems, transforming them from being passive and helpless to being “active, resourceful, competent,” Dr. Turk said.

By utilizing real examples in a patient's life, CBT can help individuals recognize unhelpful thinking patterns such as overgeneralization, catastrophizing, seeing things in all-or-none terms, jumping to conclusions, selectively focusing on details rather than the big picture, and mind-reading the thoughts of others.

A CBT therapist then helps a patient learn to recognize problems associated with a life of pain and then propose his or her own adaptive solutions. Examples might include feeling bored and restless because of diminished activities, experiencing disharmony in family members due to altered roles, or suffering diminished self-esteem when a patient in chronic pain can no longer work.

A good CBT therapist guides the patient to set realistic solutions approached with step-by-step goals, practiced in sessions and during homework sessions tracked with diaries and charts.

Dr. Turk said he makes success highly attainable from session to session. For example, if increased mobility is a goal and the patient already believes he can walk 1 block, he sets the bar at walking 8/10 of a block every few days for the first week.

Monitoring, reinforcement, listening, and adapting to changing realities are all key to CBT success. Perhaps most important is the anticipation of nonadherence. Right from the start, a therapist can tell patients to expect flare-ups in pain and “slip-ups” in behavior, and a plan can be devised to deal with those situations before they occur.

To illustrate how CBT can work, Dr. Turk recounted the case of an elderly woman with chronic neck pain so severe that her husband retired from his job to care for her. During CBT she identified inactivity as a problem and set a goal of beginning to cook again. A plan was established for her to prepare one meal a day.

During her next visit, the patient's checklist revealed that she had not kept her goal. It seems her husband became nervous when she would begin to cook, telling her she should rest because she “didn't look too good.” He would then prepare the meal.

In this case, moving forward with the CBT plan first required a “husbandectomy,” in which the husband was encouraged to attend some activities at a nearby senior center so that his wife could begin to regain her self-esteem and meet her self-defined goals.

The 10 Rules of CBT Adherence

1. Anticipate nonadherence.

2. Consider the prescribed regimen from the patient's perspective.

3. Foster a collaborative relationship based on negotiation.

4. Prepare for flare-ups.

5. Customize treatment.

6. Enlist family support.

7. Provide a system of continuity and accessibility.

8. Make use of other health care providers (such as occupational or physical therapists) as well as community resources.

9. Repeat, repeat, repeat everything.

10. Don't give up! Pain specialists represent Ellis Island or Lourdes to chronic pain patients. If they were easy patients, “they wouldn't be seeing you.”

Source: Dr. Turk

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases–especially when self-inflicted wounds are deep and in potentially lethal locations–the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad–and not necessarily a deviant one–that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts–or even when she experiences the physical pain of a recent wound–she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases–especially when self-inflicted wounds are deep and in potentially lethal locations–the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad–and not necessarily a deviant one–that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts–or even when she experiences the physical pain of a recent wound–she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.

Self-injurious behavior in the form of “cutting” may not be as rare as child psychiatrists once believed, nor is it always a red flag for imminent suicide.

Instead, it may be an attempt by a severely disconnected, depressed teenager to gain focus and control, said Michael Jellinek, M.D., chief of child psychiatry at Massachusetts General Hospital in Boston.

“Cutting means different things to different individuals, and it occurs in a variety of settings and circumstances. Often, it's profoundly misunderstood,” Dr. Jellinek told this newspaper.

Child psychiatrists once assumed that cutting was a precursor to suicide. And although this is true in some cases–especially when self-inflicted wounds are deep and in potentially lethal locations–the majority of children and adolescents who purposefully cut themselves do not have an immediate wish or intent to kill themselves.

“I see superficial, repetitive cutting as a behavior that spans a wide spectrum of motivations, from a me-too form of self-expression to a sign of deep emotional pain and dissociation,” he said.

In its most benign form, cutting is an outgrowth of a societal change in which the body is used as a template.

“As technology makes our lives more anonymous, many young people communicate their individuality by using their bodies as canvases,” Dr. Jellinek said. Body piercings or tattoos may represent a spectrum of meaning that ranges from a display of fashion sense to a screaming need for recognition.

For example, piercings may be subtle, as in the piercing of an ear or navel, or extreme, as in multiple piercings involving the face, breasts, and genitals, he explained. Tattoos can be small, unobtrusive designs on the ankle or small of the back, or can constitute an aggressive, bodywide statement that is impossible to cover with clothing.

In this context, superficial decorative cutting may be the self-expression of a fairly untroubled adolescent who is copying a behavior from a more disturbed acquaintance, or a fad–and not necessarily a deviant one–that is followed by a group of friends, said Dr. Jellinek.

He cited a hypothetical patient, Brian, an otherwise well-functioning teenager who, after a sad experience or while very anxious during exam time, makes small cuts on his forearm with the sharp edge of a paper clip to mimic the cutting he's witnessed in a friend with major depression. He might tell other friends about this behavior as a means of seeking reassurance or empathy.

For another hypothetical patient, Maria, cutting may arise from acute depression and self-recrimination. She may have cut herself at a moment when she felt life was not worth living, not to actually take her life but as a suicidal gesture, a cry for help, and a punishment in which the external pain is a substitute for even more overwhelming inner pain.

Meanwhile, another adolescent, Katie, may secretly cut herself in a more serious, repetitive manner. Her wounds may form a pattern. She may cut herself obsessively every day, more deeply each time, hiding scars in various stages of healing as she pulls away from friends and family, drops out of activities, and sees her grades plummet.

It's vital for family physicians to realize that to Brian, Maria, and especially Katie, cutting feels like a solution, not a problem.

The cutting behavior awakens Katie from a disconnected emotional state to which she escapes when she is overwhelmed by despondency, anxiety, and low self-esteem. When she cuts–or even when she experiences the physical pain of a recent wound–she feels focused, appropriately punished, and a bit more in touch with herself. Cutting is something over which she has control.

“If you discover Katie's cutting and react with horror, you will unknowingly add to her sense of shame over a behavior that is the only way she has found to relieve her emotional torment,” Dr. Jellinek advised.

“Instead, if you notice injuries and explain in a nonjudgmental way that you know of teenagers who try to help themselves through difficult times by cutting, she may feel a tremendous sense of relief.”

He recommended that family physicians take the time to explain that they're willing to help the patient try to understand why he or she has chosen cutting as a solution, and what the real problem may be.

“Let her know that you may be able to help her find other alternatives that will help her achieve the same goal: feeling connected, strong, and in control.”

Dr. Jellinek characterized cutting as a highly complex symptom of deeper psychological issues. Sorting out the intrapsychic states of adolescents as they think about cutting and then cut themselves is a difficult task, even for a mental health clinician with experience and training in this area.

He tapped pediatricians and family physicians as important “first responders” who can help by being uncritical, understanding, and open to patients' explanations of their cutting behavior.

“Recognizing the cutting as a solution rather than as the whole problem is a critical first step,” he said.