Damian McNamara

ORLANDO — About 25% of children newly diagnosed with Crohn's disease will develop perianal fistulas within 2 years, but the majority of these fistulas will resolve in response to medical management alone, Dr. David J. Keljo reported at a poster session at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Using data from a prospective, observational registry that enrolled pediatric patients with irritable bowel disease (IBD), investigators assessed outcomes for 263 children under age 16 years newly diagnosed with Crohn's disease. All participants had at least 24 months of follow-up.

Dr. Keljo and his associates from the Pediatric IBD Collaborative Research Group in Hartford, Conn., studied the frequency and clinical course of perianal fistulas in these children. Roughly 25% had fistulas within the first 2 years, and three-quarters of the latter children had them within the first 30 days.

Fistulizing patients were more likely than nonfistulizing patients to be treated with infliximab, 6MP/AZA6 [mercaptopurine (6MP) and its prodrug azathioprine (AZA)], methotrexate, and antibiotics.

A total of 47 children (18%) had fistulas by day 30 after diagnosis. Of these, fistulas resolved in 35 (75%) patients, including 7 whose fistulas resolved after infliximab therapy. None required surgery, said Dr. Keljo, who is on the pediatric gastroenterology staff at Children's Hospital of Pittsburgh. Another 18 patients (7%) developed lesions after 30 days but before 2 years.

ORLANDO — About 25% of children newly diagnosed with Crohn's disease will develop perianal fistulas within 2 years, but the majority of these fistulas will resolve in response to medical management alone, Dr. David J. Keljo reported at a poster session at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Using data from a prospective, observational registry that enrolled pediatric patients with irritable bowel disease (IBD), investigators assessed outcomes for 263 children under age 16 years newly diagnosed with Crohn's disease. All participants had at least 24 months of follow-up.

Dr. Keljo and his associates from the Pediatric IBD Collaborative Research Group in Hartford, Conn., studied the frequency and clinical course of perianal fistulas in these children. Roughly 25% had fistulas within the first 2 years, and three-quarters of the latter children had them within the first 30 days.

Fistulizing patients were more likely than nonfistulizing patients to be treated with infliximab, 6MP/AZA6 [mercaptopurine (6MP) and its prodrug azathioprine (AZA)], methotrexate, and antibiotics.

A total of 47 children (18%) had fistulas by day 30 after diagnosis. Of these, fistulas resolved in 35 (75%) patients, including 7 whose fistulas resolved after infliximab therapy. None required surgery, said Dr. Keljo, who is on the pediatric gastroenterology staff at Children's Hospital of Pittsburgh. Another 18 patients (7%) developed lesions after 30 days but before 2 years.

ORLANDO — About 25% of children newly diagnosed with Crohn's disease will develop perianal fistulas within 2 years, but the majority of these fistulas will resolve in response to medical management alone, Dr. David J. Keljo reported at a poster session at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Using data from a prospective, observational registry that enrolled pediatric patients with irritable bowel disease (IBD), investigators assessed outcomes for 263 children under age 16 years newly diagnosed with Crohn's disease. All participants had at least 24 months of follow-up.

Dr. Keljo and his associates from the Pediatric IBD Collaborative Research Group in Hartford, Conn., studied the frequency and clinical course of perianal fistulas in these children. Roughly 25% had fistulas within the first 2 years, and three-quarters of the latter children had them within the first 30 days.

Fistulizing patients were more likely than nonfistulizing patients to be treated with infliximab, 6MP/AZA6 [mercaptopurine (6MP) and its prodrug azathioprine (AZA)], methotrexate, and antibiotics.

A total of 47 children (18%) had fistulas by day 30 after diagnosis. Of these, fistulas resolved in 35 (75%) patients, including 7 whose fistulas resolved after infliximab therapy. None required surgery, said Dr. Keljo, who is on the pediatric gastroenterology staff at Children's Hospital of Pittsburgh. Another 18 patients (7%) developed lesions after 30 days but before 2 years.

ORLANDO — Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants—the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine—showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. They can have poor driving skills, Dr. Jensen added. Adults with the disorder are inattentive, poorly organized, restless, emotionally reactive, and commonly miss deadlines or appointments.

“ADHD—the full syndrome—is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip in terms of whether they are doing better. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said.

Stimulants can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in the day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to—you cannot unswallow a pill. It is also a good option for kids who cannot swallow a pill.” A disadvantage is its relatively large size, which increases with the dose. Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response.”

Disadvantages of methylphenidate and the amphetamines include a potential for tolerance and/or psychological dependence, Dr. Jensen said. Also, he said, these agents may worsen motor and phonic tics, and suppress long-term growth.

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

ORLANDO — Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants—the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine—showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. They can have poor driving skills, Dr. Jensen added. Adults with the disorder are inattentive, poorly organized, restless, emotionally reactive, and commonly miss deadlines or appointments.

“ADHD—the full syndrome—is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip in terms of whether they are doing better. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said.

Stimulants can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in the day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to—you cannot unswallow a pill. It is also a good option for kids who cannot swallow a pill.” A disadvantage is its relatively large size, which increases with the dose. Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response.”

Disadvantages of methylphenidate and the amphetamines include a potential for tolerance and/or psychological dependence, Dr. Jensen said. Also, he said, these agents may worsen motor and phonic tics, and suppress long-term growth.

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

ORLANDO — Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants—the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine—showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. They can have poor driving skills, Dr. Jensen added. Adults with the disorder are inattentive, poorly organized, restless, emotionally reactive, and commonly miss deadlines or appointments.

“ADHD—the full syndrome—is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip in terms of whether they are doing better. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said.

Stimulants can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in the day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to—you cannot unswallow a pill. It is also a good option for kids who cannot swallow a pill.” A disadvantage is its relatively large size, which increases with the dose. Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response.”

Disadvantages of methylphenidate and the amphetamines include a potential for tolerance and/or psychological dependence, Dr. Jensen said. Also, he said, these agents may worsen motor and phonic tics, and suppress long-term growth.

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

ORLANDO — Two neurologic systems reinforce alcohol dependence—both dopamine and serotonin pathways—and make it more difficult for people to stop drinking, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” said George F. Koob, Ph.D., professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif.

Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems, Dr. Koob said. The pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in the brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating. …Those people you knew in college who could drink everyone under the table ultimately end up with a problem.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are brain areas that might contribute to dependence, he added.

Consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys—the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent—you lose the good guys and gain the brain stress system—so you continue to self-medicate with your drug of choice.”

ORLANDO — Two neurologic systems reinforce alcohol dependence—both dopamine and serotonin pathways—and make it more difficult for people to stop drinking, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” said George F. Koob, Ph.D., professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif.

Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems, Dr. Koob said. The pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in the brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating. …Those people you knew in college who could drink everyone under the table ultimately end up with a problem.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are brain areas that might contribute to dependence, he added.

Consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys—the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent—you lose the good guys and gain the brain stress system—so you continue to self-medicate with your drug of choice.”

ORLANDO — Two neurologic systems reinforce alcohol dependence—both dopamine and serotonin pathways—and make it more difficult for people to stop drinking, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” said George F. Koob, Ph.D., professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif.

Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems, Dr. Koob said. The pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in the brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating. …Those people you knew in college who could drink everyone under the table ultimately end up with a problem.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are brain areas that might contribute to dependence, he added.

Consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys—the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent—you lose the good guys and gain the brain stress system—so you continue to self-medicate with your drug of choice.”

ORLANDO – Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very shortacting drug with a half-life of 1 to 2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor).

“It can take up to a week for full effect, so caution patients that they may not feel tired right away,” said Dr. Mendelson, who is also a consultant, an adviser, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said.

“No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.” Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign–but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder. Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

ORLANDO – Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very shortacting drug with a half-life of 1 to 2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor).

“It can take up to a week for full effect, so caution patients that they may not feel tired right away,” said Dr. Mendelson, who is also a consultant, an adviser, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said.

“No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.” Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign–but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder. Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

ORLANDO – Ramelteon is effective for a subset of patients with insomnia, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute. In addition, because the agent works on melatonin receptors, a potential off-label use is for patients with shift-work disorder.

Ramelteon (Rozerem, Takeda Pharmaceuticals) targets the melatonin receptors MT1 and MT2. The agent is approximately 10 times more potent than melatonin. Other approved drugs promote sleep by increasing γ-aminobutyric acid (GABA), which is normally released by the suprachiasmatic nucleus in the brain.

“Ramelteon is a very interesting drug. It is the first on the market for sleep that does not work on the GABA system,” Dr. Wallace B. Mendelson said. The melatonin receptor agonist is a very shortacting drug with a half-life of 1 to 2 hours. “It is very potent for helping people fall asleep but not as effective for those who wake up early. So it's for a subset of patients.”

The Food and Drug Administration approved ramelteon for treatment of insomnia characterized by difficulty with sleep onset. “It is not a DEA classified substance, only a hypnotic without potential for dependence,” said Dr. Mendelson, psychopharmacology consultant for many pharmaceutical companies, including Takeda Pharmaceuticals North America Inc.

A delay to peak therapeutic effect is another distinction of ramelteon, compared with benzodiazepines and newer, nonbenzodiazepine GABA agonists such as zolpidem (Ambien, Sanofi-Aventis) or eszopiclone (Lunesta, Sepracor).

“It can take up to a week for full effect, so caution patients that they may not feel tired right away,” said Dr. Mendelson, who is also a consultant, an adviser, and on the speakers' bureau for Sanofi-Aventis and Sepracor Inc.

People with shift-work sleep disorder can experience excessive daytime sleepiness because their body rhythm stays the same but the world changes around them, Dr. Mendelson said.

“No one knows why some people are more susceptible to this, except it is harder to adapt to nighttime shift work as you get older.”

Pharmacotherapy with a sleep aid might be sufficient for a shift worker who complains only of sleepiness or trouble going off to sleep, Dr. Mendelson said. However, “if they are having trouble with both sleep and waking, it might make sense to try to help them shift to the new time. One way is to use melatonin.” Exogenous melatonin can shift circadian rhythms. Melatonin taken in the evening can shift a person's circadian rhythm earlier while melatonin in the morning can shift it later, he said.

“I have a real issue with the quality and standardization of melatonin. It's not consistent, which is why I prefer a drug like Rozerem,” Dr. Mendelson said. “Rozerem is not indicated for this, but some research indicates it can shift circadian rhythm with off-label use similar to melatonin.”

Another option for circadian rhythm adjustment is bright light therapy. “I like bright light therapy because it's more benign–but it works the opposite.” In the morning, the therapy pushes circadian rhythm phase earlier, and at night, it pushes it later.

Insomnia rarely occurs alone, Dr. Mendelson said. “About 80% of insomnia patients you see have some other disorder. The old name was secondary insomnia. Us sleep guys are now calling this comorbid insomnia.”

Ramelteon might be an appropriate choice for patients with sleep apnea, Dr. Mendelson said. A significant minority of sleep apnea will present with insomnia as the primary complaint. “We need to carefully diagnose because most of the agents we prescribe for insomnia can make sleep apnea worse, except ramelteon or the tricyclic antidepressants.”

The probability of diagnosing a psychiatric disorder increases among patients who complain of insomnia (Sleep Med. 2005;6:549–53). In this study, a survey of 200 general hospital patients indicated 57% reported insomnia and 50% reported at least one psychiatric disorder. Insomnia can play a major role in several psychiatric illnesses, especially depression, Dr. Mendelson said. “Targeting insomnia with sleep aids and behavioral therapy can improve outcomes.” Insomnia may also signal depression onset. “On average, 41% of people will have insomnia preceding depression.”

ORLANDO – It is a good idea to routinely ask patients–particularly those with risk factors for dependence–about their alcohol use, George F. Koob, Ph.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

However, patients are not always honest, copresenter Dr. Stephen M. Stahl pointed out. “Most of us try to screen patients for alcohol, but … I can't tell you the number of times I've been bamboozled by patients.

“In clinical practice, there are a lot of people who are heavy drinkers who do not think of themselves as alcoholics. They will be completely insulted if you tell them,” said Dr. Stahl of the department of psychiatry, University of California, San Diego, and chairman of the institute.

He and Dr. Koob, professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif., recommended use of the Alcohol Use Disorders Identification Test (AUDIT). However, 84% of those attending the meeting indicated they have never used the AUDIT screening tool, according to an electronic poll.

According to Dr. Koob, two neurologic systems reinforce alcohol dependence–both dopamine and serotonin pathways–and make it more difficult for people to stop drinking, and advances in neurobiology are offering new insights into how the brain is altered by alcohol use, dependence, and withdrawal.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” Dr. Koob said. Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems.

Researchers have long proposed that the pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. “So it's a combination of the opioids and dopamine effects that causes a pleasurable experience.”

Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating,” he noted.

“Those people you knew in college who could drink everyone under the table ultimately end up with a problem,” Dr. Koob said. “That starts the neuroadaptive process, so they end up needing that [higher] amount of alcohol.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are the brain areas that might contribute to dependence, Dr. Koob added.

Neurobiologists have found that consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys–the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent–you lose the good guys and gain the brain stress system–so you continue to self-medicate with your drug of choice.”

ORLANDO – It is a good idea to routinely ask patients–particularly those with risk factors for dependence–about their alcohol use, George F. Koob, Ph.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

However, patients are not always honest, copresenter Dr. Stephen M. Stahl pointed out. “Most of us try to screen patients for alcohol, but … I can't tell you the number of times I've been bamboozled by patients.

“In clinical practice, there are a lot of people who are heavy drinkers who do not think of themselves as alcoholics. They will be completely insulted if you tell them,” said Dr. Stahl of the department of psychiatry, University of California, San Diego, and chairman of the institute.

He and Dr. Koob, professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif., recommended use of the Alcohol Use Disorders Identification Test (AUDIT). However, 84% of those attending the meeting indicated they have never used the AUDIT screening tool, according to an electronic poll.

According to Dr. Koob, two neurologic systems reinforce alcohol dependence–both dopamine and serotonin pathways–and make it more difficult for people to stop drinking, and advances in neurobiology are offering new insights into how the brain is altered by alcohol use, dependence, and withdrawal.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” Dr. Koob said. Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems.

Researchers have long proposed that the pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. “So it's a combination of the opioids and dopamine effects that causes a pleasurable experience.”

Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating,” he noted.

“Those people you knew in college who could drink everyone under the table ultimately end up with a problem,” Dr. Koob said. “That starts the neuroadaptive process, so they end up needing that [higher] amount of alcohol.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are the brain areas that might contribute to dependence, Dr. Koob added.

Neurobiologists have found that consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys–the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent–you lose the good guys and gain the brain stress system–so you continue to self-medicate with your drug of choice.”

ORLANDO – It is a good idea to routinely ask patients–particularly those with risk factors for dependence–about their alcohol use, George F. Koob, Ph.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

However, patients are not always honest, copresenter Dr. Stephen M. Stahl pointed out. “Most of us try to screen patients for alcohol, but … I can't tell you the number of times I've been bamboozled by patients.

“In clinical practice, there are a lot of people who are heavy drinkers who do not think of themselves as alcoholics. They will be completely insulted if you tell them,” said Dr. Stahl of the department of psychiatry, University of California, San Diego, and chairman of the institute.

He and Dr. Koob, professor and chairman of the committee on the neurobiology of addictive disorders at the Scripps Research Institute, La Jolla, Calif., recommended use of the Alcohol Use Disorders Identification Test (AUDIT). However, 84% of those attending the meeting indicated they have never used the AUDIT screening tool, according to an electronic poll.

According to Dr. Koob, two neurologic systems reinforce alcohol dependence–both dopamine and serotonin pathways–and make it more difficult for people to stop drinking, and advances in neurobiology are offering new insights into how the brain is altered by alcohol use, dependence, and withdrawal.

“The neurobiology has led us where there are spectacular new targets for treatment of alcoholism,” Dr. Koob said. Rewarding effects of alcohol may be mediated by dopaminergic and opioidergic systems.

Researchers have long proposed that the pleasure provided through the mesolimbic pathway explains why people initially drink alcohol or take drugs. Dopamine is released in the front end of the brain while opioids activate the ventral tegmental area and nucleus accumbens. “So it's a combination of the opioids and dopamine effects that causes a pleasurable experience.”

Impulsive drinking, particularly in young males, is an activation of reward mechanisms driven by initial pleasurable effects, Dr. Koob said. “As a person continues to drink, the reward system gets impaired but hyperarousal in brain is set up that only alcohol will suppress. So [drinking] becomes self-medicating,” he noted.

“Those people you knew in college who could drink everyone under the table ultimately end up with a problem,” Dr. Koob said. “That starts the neuroadaptive process, so they end up needing that [higher] amount of alcohol.”

The acute double action of alcohol is to enhance γ-aminobutyric acid (GABA) and decrease glutamate, Dr. Koob said. Both dopamine and serotonin pathways may mediate alcohol dependence. The frontal cortex, amygdala, and hippocampus are the brain areas that might contribute to dependence, Dr. Koob added.

Neurobiologists have found that consumption of alcohol also may alter regulatory agents of stress, particularly increasing corticotropin releasing factor (CRF) activity and decreasing neuropeptide Y. “While you are bingeing on alcohol, you are releasing the good guys like dopamine peptides, but when you get into withdrawal, you are recruiting the bad guys–the GABA system and the CRF stress hormone,” Dr. Koob said.

“You have a double-whammy effect when you become dependent–you lose the good guys and gain the brain stress system–so you continue to self-medicate with your drug of choice.”

ORLANDO – Therapeutic biofeedback reduces pain intensity, pain frequency, and health care utilization among children with recurrent abdominal pain, according to two posters presented at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Biofeedback “is noninvasive and it empowers the kids. It gives them the tools to make themselves better,” Dr. Warren Shapiro said in an interview.

“Biofeedback has long-lasting effects.” Unlike more common acute interventions, “it's really a long-lasting solution,” coauthor Eric Sowder, Ph.D., said.

The researchers decided to assess biofeedback in this pediatric population because “there has not been very much in terms of long-lasting therapies for abdominal pain,” said Dr. Shapiro, a pediatric gastroenterologist at the Southern California Kaiser Permanente Medical Group in San Diego.

Data indicate biofeedback is feasible for adults in a primary care setting (Appl. Psychophysiol. Biofeedback 2004;29:79–93). “It has not been researched as well in kids. But we see they are getting better,” said Dr. Sowder, psychological assistant in biofeedback and behavioral medicine, Alliant International University, San Diego.

Dr. Shapiro, Dr. Sowder, and their associates assessed 64 children referred to pediatric gastroenterology with recurrent abdominal pain. Pain frequency, intensity, and autonomic nervous system functioning were compared before and after an average of six biofeedback sessions.

Biofeedback might help children with recurrent abdominal pain to adapt their pain behavior. The technique addresses a proposed deficit in their autonomic nervous system response to stress. Also, biofeedback might help these patients counter an enhanced subjective response to pain.

To test these theories, pediatric gastroenterologists referred participants with recurrent abdominal pain. Patient ages ranged from 7 to 18 years, and 70% were female. Pain episodes per week were compared before and after completion of biofeedback, and pain intensity was rated on a 1–10 visual analog scale.

Biofeedback significantly reduced the intensity and frequency of pain. Mean pain intensity ratings decreased from 6 to 2.5; mean number of pain episodes per week decreased from seven to three.

Researchers compared peak-to-valley differences in respiratory sinus arrhythmia (RSA) to reflect autonomic nervous system functioning. The RSA during rest increased significantly, from 13.6 before biofeedback to 22.5 afterward. The RSA during slow-paced breathing likewise increased, from 22 to 32.5.

These findings suggest that biofeedback should be considered a first-line therapy for childhood recurrent abdominal pain, the researchers wrote. “We want to do more research and have a control group, and maybe compare this to hypnosis,” Dr. Sowder said.

A second study demonstrated that “primary care and [emergency department] visits come down” with biofeedback, Dr. Sowder said. He, Dr. Shapiro, and a colleague demonstrated a significant reduction in health care utilization following biofeedback training of children with recurrent abdominal pain.

The researchers identified 39 children (mean age 13 years) who were diagnosed with recurrent abdominal pain and completed a mean of five biofeedback sessions. They compared health care utilization 2 years prior to biofeedback and 1 year afterward in a Kaiser Permanente database.

Biofeedback significantly reduced mean primary care visits from 10.3 to 3.8 per year; emergency department visits from 0.69 to 0.05; prescriptions from 8.8 to 4.5; and diagnostic tests from 0.77 to 0.08.

ORLANDO – Therapeutic biofeedback reduces pain intensity, pain frequency, and health care utilization among children with recurrent abdominal pain, according to two posters presented at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Biofeedback “is noninvasive and it empowers the kids. It gives them the tools to make themselves better,” Dr. Warren Shapiro said in an interview.

“Biofeedback has long-lasting effects.” Unlike more common acute interventions, “it's really a long-lasting solution,” coauthor Eric Sowder, Ph.D., said.

The researchers decided to assess biofeedback in this pediatric population because “there has not been very much in terms of long-lasting therapies for abdominal pain,” said Dr. Shapiro, a pediatric gastroenterologist at the Southern California Kaiser Permanente Medical Group in San Diego.

Data indicate biofeedback is feasible for adults in a primary care setting (Appl. Psychophysiol. Biofeedback 2004;29:79–93). “It has not been researched as well in kids. But we see they are getting better,” said Dr. Sowder, psychological assistant in biofeedback and behavioral medicine, Alliant International University, San Diego.

Dr. Shapiro, Dr. Sowder, and their associates assessed 64 children referred to pediatric gastroenterology with recurrent abdominal pain. Pain frequency, intensity, and autonomic nervous system functioning were compared before and after an average of six biofeedback sessions.

Biofeedback might help children with recurrent abdominal pain to adapt their pain behavior. The technique addresses a proposed deficit in their autonomic nervous system response to stress. Also, biofeedback might help these patients counter an enhanced subjective response to pain.

To test these theories, pediatric gastroenterologists referred participants with recurrent abdominal pain. Patient ages ranged from 7 to 18 years, and 70% were female. Pain episodes per week were compared before and after completion of biofeedback, and pain intensity was rated on a 1–10 visual analog scale.

Biofeedback significantly reduced the intensity and frequency of pain. Mean pain intensity ratings decreased from 6 to 2.5; mean number of pain episodes per week decreased from seven to three.

Researchers compared peak-to-valley differences in respiratory sinus arrhythmia (RSA) to reflect autonomic nervous system functioning. The RSA during rest increased significantly, from 13.6 before biofeedback to 22.5 afterward. The RSA during slow-paced breathing likewise increased, from 22 to 32.5.

These findings suggest that biofeedback should be considered a first-line therapy for childhood recurrent abdominal pain, the researchers wrote. “We want to do more research and have a control group, and maybe compare this to hypnosis,” Dr. Sowder said.

A second study demonstrated that “primary care and [emergency department] visits come down” with biofeedback, Dr. Sowder said. He, Dr. Shapiro, and a colleague demonstrated a significant reduction in health care utilization following biofeedback training of children with recurrent abdominal pain.

The researchers identified 39 children (mean age 13 years) who were diagnosed with recurrent abdominal pain and completed a mean of five biofeedback sessions. They compared health care utilization 2 years prior to biofeedback and 1 year afterward in a Kaiser Permanente database.

Biofeedback significantly reduced mean primary care visits from 10.3 to 3.8 per year; emergency department visits from 0.69 to 0.05; prescriptions from 8.8 to 4.5; and diagnostic tests from 0.77 to 0.08.

ORLANDO – Therapeutic biofeedback reduces pain intensity, pain frequency, and health care utilization among children with recurrent abdominal pain, according to two posters presented at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Biofeedback “is noninvasive and it empowers the kids. It gives them the tools to make themselves better,” Dr. Warren Shapiro said in an interview.

“Biofeedback has long-lasting effects.” Unlike more common acute interventions, “it's really a long-lasting solution,” coauthor Eric Sowder, Ph.D., said.

The researchers decided to assess biofeedback in this pediatric population because “there has not been very much in terms of long-lasting therapies for abdominal pain,” said Dr. Shapiro, a pediatric gastroenterologist at the Southern California Kaiser Permanente Medical Group in San Diego.

Data indicate biofeedback is feasible for adults in a primary care setting (Appl. Psychophysiol. Biofeedback 2004;29:79–93). “It has not been researched as well in kids. But we see they are getting better,” said Dr. Sowder, psychological assistant in biofeedback and behavioral medicine, Alliant International University, San Diego.

Dr. Shapiro, Dr. Sowder, and their associates assessed 64 children referred to pediatric gastroenterology with recurrent abdominal pain. Pain frequency, intensity, and autonomic nervous system functioning were compared before and after an average of six biofeedback sessions.

Biofeedback might help children with recurrent abdominal pain to adapt their pain behavior. The technique addresses a proposed deficit in their autonomic nervous system response to stress. Also, biofeedback might help these patients counter an enhanced subjective response to pain.

To test these theories, pediatric gastroenterologists referred participants with recurrent abdominal pain. Patient ages ranged from 7 to 18 years, and 70% were female. Pain episodes per week were compared before and after completion of biofeedback, and pain intensity was rated on a 1–10 visual analog scale.

Biofeedback significantly reduced the intensity and frequency of pain. Mean pain intensity ratings decreased from 6 to 2.5; mean number of pain episodes per week decreased from seven to three.

Researchers compared peak-to-valley differences in respiratory sinus arrhythmia (RSA) to reflect autonomic nervous system functioning. The RSA during rest increased significantly, from 13.6 before biofeedback to 22.5 afterward. The RSA during slow-paced breathing likewise increased, from 22 to 32.5.

These findings suggest that biofeedback should be considered a first-line therapy for childhood recurrent abdominal pain, the researchers wrote. “We want to do more research and have a control group, and maybe compare this to hypnosis,” Dr. Sowder said.

A second study demonstrated that “primary care and [emergency department] visits come down” with biofeedback, Dr. Sowder said. He, Dr. Shapiro, and a colleague demonstrated a significant reduction in health care utilization following biofeedback training of children with recurrent abdominal pain.

The researchers identified 39 children (mean age 13 years) who were diagnosed with recurrent abdominal pain and completed a mean of five biofeedback sessions. They compared health care utilization 2 years prior to biofeedback and 1 year afterward in a Kaiser Permanente database.

Biofeedback significantly reduced mean primary care visits from 10.3 to 3.8 per year; emergency department visits from 0.69 to 0.05; prescriptions from 8.8 to 4.5; and diagnostic tests from 0.77 to 0.08.

ORLANDO – Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants–the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine–showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. “ADHD–the full syndrome–is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said. “I graph them and show them to families–they love them.”

Stimulant medications can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to–you cannot unswallow a pill. It is also good option for kids who cannot swallow a pill.”

A disadvantage is its relatively large size, which increases with the dose.

Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting. What I would urge you not to do is start with long-acting and add short-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response and side effects.”

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

A new lysine prodrug of d-amphetamine is in development. It is designed for slower release onto the receptor and potentially less stimulation and abuse potential. “The company has an approvable letter from the FDA,” Dr. Jensen said. “Will it be as effective with lower side effects? That remains to be seen.”

ORLANDO – Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants–the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine–showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. “ADHD–the full syndrome–is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said. “I graph them and show them to families–they love them.”

Stimulant medications can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to–you cannot unswallow a pill. It is also good option for kids who cannot swallow a pill.”

A disadvantage is its relatively large size, which increases with the dose.

Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting. What I would urge you not to do is start with long-acting and add short-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response and side effects.”

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

A new lysine prodrug of d-amphetamine is in development. It is designed for slower release onto the receptor and potentially less stimulation and abuse potential. “The company has an approvable letter from the FDA,” Dr. Jensen said. “Will it be as effective with lower side effects? That remains to be seen.”

ORLANDO – Start with a long-acting stimulant for treatment of attention-deficit hyperactivity disorder for most patients, increase the dose before adding a short-acting drug, and monitor response with a rating scale, Dr. Peter S. Jensen advised at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Begin with intensive treatment, because studies show it can make a difference up to 2 years out, Dr. Jensen said. “We now have studies of the stimulants–the methylphenidate preparations, the amphetamine, dextroamphetamine, and atomoxetine–showing sustained benefit through 12 months and up to 2 years.”

The symptom profile for attention-deficit hyperactivity disorder (ADHD) evolves with age. Hyperactivity, impulsivity, aggression, distractibility, a low frustration tolerance, and difficulty with establishing routines are among the childhood symptoms. “Individuals with predominantly inattentive symptoms are more likely to be overlooked,” said Dr. Jensen, director, Center for the Advancement of Children's Mental Health, department of child psychiatry, Columbia University, New York.

Adolescents with ADHD are often easily distracted/inattentive, easily bored, impatient, and emotionally immature, compared with peers. “ADHD–the full syndrome–is rarely seen in adults. So many kids initially diagnosed with the full syndrome lose a lot of the hyperactivity and impulsivity as they get older,” Dr. Jensen said. “What remains? Inattention (J. Clin. Psychol. 2005;61:535–47).

Monitor treatment response with age-appropriate rating scales, Dr. Jensen suggested. Examples include the Early Childhood Attention Deficit Disorder Evaluation scale for preschool children; the Child Behavior Checklist for school-age children; and the Adolescent Symptom Inventory for adolescents. In addition, the Brown Attention Deficit Disorder scales are useful for patients who are primarily inattentive.

“If we don't use these, we are shooting from the hip. We get parent ratings and teacher ratings with these and it's great documentation,” Dr. Jensen said. “I graph them and show them to families–they love them.”

Stimulant medications can be effective for both motor and attention symptoms of ADHD. “Avoid dosing late in day, because of risk of insomnia. Children who are not growing or gaining weight should stop treatment, at least temporarily,” Dr. Jensen said. “If a kid is not in terrible trouble on the weekends, you might consider [drug] holidays.”

The stimulant methylphenidate is available in various long-acting formulations. For example, the methylphenidate transdermal system (Daytrana, Shire) was approved by the Food and Drug Administration in April 2006. “I have not used it yet, but it's a very interesting strategy,” Dr. Jensen said. “You can remove the patch if you want to–you cannot unswallow a pill. It is also good option for kids who cannot swallow a pill.”

A disadvantage is its relatively large size, which increases with the dose.

Onset of action is gradual and can take up to 2 hours after application. Peak administration typically takes 7–9 hours. A single patch can provide all-day efficacy (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:522–9).

Duration of any methylphenidate should be balanced against the potential for side effects, most commonly, impaired sleep and appetite, Dr. Jensen said. “Except for very young children, start with long-acting. What I would urge you not to do is start with long-acting and add short-acting.”

Not all methylphenidate is created equal. “A lot of these medications will have different percentages of short-acting beads and long-acting beads,” Dr. Jensen said. “Even though it is the same molecule, you will see different peaks. How the body responds to these slopes can lead to significant person-to-person variations in response and side effects.”

He said he generally goes to the methylphenidate products sooner because they have less potential for abuse than amphetamines. Amphetamines, however, “may have more of a punch of action for efficacy versus methylphenidate.”

A new lysine prodrug of d-amphetamine is in development. It is designed for slower release onto the receptor and potentially less stimulation and abuse potential. “The company has an approvable letter from the FDA,” Dr. Jensen said. “Will it be as effective with lower side effects? That remains to be seen.”

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."

LAS VEGAS—Ablative fractional resurfacing shows promise for skin resurfacing and tightening, according to the first studies conducted on use of the technology.

Considered a more intense treatment than nonablative fractional devices, the ablative fractional laser could hypothetically mitigate the risks that are traditionally associated with ablative laser resurfacing.

"Will this ablative resurfacing really be the middle ground?" Dr. Zakia Rahman asked at an international symposium on cosmetic and laser surgery.

Nonablative fractional resurfacing devices such as Fraxel were developed to produce results similar to those of ablative laser resurfacing with less downtime for patients. With ablative fractional resurfacing, there is more downtime, although it is still less than with ablative laser treatments, noted Dr. Rahman, who is with Stanford (Calif.) University.

Initial ex vivo studies of ablative fractional resurfacing on human skin revealed the degree of skin tightening possible at different energy settings: 20 mJ produced 10% area shrinkage, 32 mJ produced 18% shrinkage, and 40 mJ yielded 23% shrinkage.

"This is really significant to me," Dr. Rahman said. At a high energy setting, 90 mJ, there was a reproducible 37% area shrinkage in the excised human tissue, she added.

Compared with nonablative devices, ablative fractional resurfacing devices increase depth of penetration. The width of the thermal treatment zones increases as the energy of the laser treatment increases. Histologic slides show annular coagulation of dermal collagen and treatment zones that get smaller as they go deeper, Dr. Rahman said.

Results might be comparable to ablative laser outcomes. "At 19 mJ you definitely get immediate tightening, similar to what you would have with a CO₂ laser," Dr. Rahman said.

Dr. Rahman also treated the forearms of 24 patients with an ablative fractional laser at settings that varied from 5 mJ per microablative zone (MAZ) to 40 mJ per MAZ. Two investigators assessed results at 1 week, 1 month, and 3 months after treatment to gauge safety and efficacy.

Further assessment consisted of full face and neck treatments at settings from 5 mJ per MAZ to 20 mJ per MAZ in 30 participants. Ten of these patients were studied at Stanford as part of this multicenter investigation.

All participants in the forearm, face, and neck assessments had subjective and objective improvement of rhytides, pigmentation, and tissue laxity, Dr. Rahman said. Another patient showed significant improvement of the perioral area.

Improvements were sustained at a follow-up assessment at 3 months. Erythema resolved by this time and no adverse effects were reported. Most participants have been followed out to 6 months in this ongoing study.

The wound-healing response that was seen represents a significant improvement over traditional ablative resurfacing, said Dr. Rahman, who is a consultant for Reliant Technologies Inc., developer of the device.

In response to a meeting attendee's question about the next step in development, Dr. Rahman said, "We are going to [a] higher energy setting now, 30 mJ, to see if we can get sustained and greater results."