Damian McNamara

BOCA RATON, FLA. — Many family physicians do not feel adequately prepared to diagnose and treat bipolar disorder, according to a small survey.

“When these mentally ill patients … present in a primary care setting, it is a critical opportunity to intervene,” according to Purvi Kobawala Smith.

Diagnosis and management of bipolar disorder can be complex, given that patients can present with severe depression, severe mania, mixed mood states, rapid cycling, and/or comorbidities.

Results of previous studies suggest that bipolar disorder often can be misunderstood or misdiagnosed in primary care settings (JAMA 2005;293:956-63; J. Clin. Psychiatry 2003;64:53-9).

“Many [patients] get misdiagnosed with depression and get sent down an entirely wrong treatment path,” Ms. Smith said in an interview at the meeting, which was sponsored by the National Institute of Mental Health.

To evaluate family physicians' educational needs regarding this disorder, Ms. Smith and her colleagues mailed surveys to 900 family physicians in January 2009. The 77 respondents (a 9% response rate) rated their own preparedness regarding screening for bipolar disorder, discussion of comorbidities, evaluation of the phase of bipolar disorder based on symptoms, discussion of psychotherapy and pharmacologic options, and development of a treatment plan.

“By and large, the majority rated themselves as 'not very prepared' or 'somewhat prepared,'” said Ms. Smith, scientific director for a medical education company in Ramsey, N.J.

More than half felt this way when asked about their ability to assess for bipolar disorder using a screening tool or interviewing techniques (36 of 69 respondents, or 52%). Another 36% felt prepared and 12%, very prepared.

Fifty-three percent of 68 felt they were not very prepared or were only somewhat prepared for discussion of comorbidities, 41% were prepared, and 6% were very prepared.

Regarding diagnosis of the phase of the disorder based on symptoms, 51% of 69 physicians felt not very or somewhat prepared, 39% felt prepared, and 10% felt very prepared.

Respondents rated themselves as less prepared to discuss psychotherapy options; Sixty-four percent of 67 physicians said they were not very prepared or were only somewhat prepared. Another 30% said they were prepared and only 6% were very prepared.

More family physicians said they were prepared or very prepared to discuss pharmacologic treatments: In all, 58% were not very prepared or only somewhat prepared, 33% were prepared, and 9% were very prepared.

Primary care physicians play an integral role in the initiation of treatment, especially when there are no psychiatrists available for referral, Ms. Smith said. She acknowledged that learning more about bipolar disorder “is a challenge for primary care physicians, given their [time] constraints.”

Along with Dr. Jennifer Payne of the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, the lead investigator of the study, Ms. Smith and others developed a free online course. Dr. Payne is the course director.

The survey and online course are supported by a grant from Eli Lilly & Co. Ms. Smith said she had no relevant disclosures. Dr. Payne is a consultant for AstraZeneca and Wyeth and receives honoraria from Wyeth.

To take the free online course, go to www.bipolarCME.com

Most of those surveyed rated themselves as inadequately prepared to diagnose bipolar disorder.

Source DR. SMITH

BOCA RATON, FLA. — Many family physicians do not feel adequately prepared to diagnose and treat bipolar disorder, according to a small survey.

“When these mentally ill patients … present in a primary care setting, it is a critical opportunity to intervene,” according to Purvi Kobawala Smith.

Diagnosis and management of bipolar disorder can be complex, given that patients can present with severe depression, severe mania, mixed mood states, rapid cycling, and/or comorbidities.

Results of previous studies suggest that bipolar disorder often can be misunderstood or misdiagnosed in primary care settings (JAMA 2005;293:956-63; J. Clin. Psychiatry 2003;64:53-9).

“Many [patients] get misdiagnosed with depression and get sent down an entirely wrong treatment path,” Ms. Smith said in an interview at the meeting, which was sponsored by the National Institute of Mental Health.

To evaluate family physicians' educational needs regarding this disorder, Ms. Smith and her colleagues mailed surveys to 900 family physicians in January 2009. The 77 respondents (a 9% response rate) rated their own preparedness regarding screening for bipolar disorder, discussion of comorbidities, evaluation of the phase of bipolar disorder based on symptoms, discussion of psychotherapy and pharmacologic options, and development of a treatment plan.

“By and large, the majority rated themselves as 'not very prepared' or 'somewhat prepared,'” said Ms. Smith, scientific director for a medical education company in Ramsey, N.J.

More than half felt this way when asked about their ability to assess for bipolar disorder using a screening tool or interviewing techniques (36 of 69 respondents, or 52%). Another 36% felt prepared and 12%, very prepared.

Fifty-three percent of 68 felt they were not very prepared or were only somewhat prepared for discussion of comorbidities, 41% were prepared, and 6% were very prepared.

Regarding diagnosis of the phase of the disorder based on symptoms, 51% of 69 physicians felt not very or somewhat prepared, 39% felt prepared, and 10% felt very prepared.

Respondents rated themselves as less prepared to discuss psychotherapy options; Sixty-four percent of 67 physicians said they were not very prepared or were only somewhat prepared. Another 30% said they were prepared and only 6% were very prepared.

More family physicians said they were prepared or very prepared to discuss pharmacologic treatments: In all, 58% were not very prepared or only somewhat prepared, 33% were prepared, and 9% were very prepared.

Primary care physicians play an integral role in the initiation of treatment, especially when there are no psychiatrists available for referral, Ms. Smith said. She acknowledged that learning more about bipolar disorder “is a challenge for primary care physicians, given their [time] constraints.”

Along with Dr. Jennifer Payne of the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, the lead investigator of the study, Ms. Smith and others developed a free online course. Dr. Payne is the course director.

The survey and online course are supported by a grant from Eli Lilly & Co. Ms. Smith said she had no relevant disclosures. Dr. Payne is a consultant for AstraZeneca and Wyeth and receives honoraria from Wyeth.

To take the free online course, go to www.bipolarCME.com

Most of those surveyed rated themselves as inadequately prepared to diagnose bipolar disorder.

Source DR. SMITH

BOCA RATON, FLA. — Many family physicians do not feel adequately prepared to diagnose and treat bipolar disorder, according to a small survey.

“When these mentally ill patients … present in a primary care setting, it is a critical opportunity to intervene,” according to Purvi Kobawala Smith.

Diagnosis and management of bipolar disorder can be complex, given that patients can present with severe depression, severe mania, mixed mood states, rapid cycling, and/or comorbidities.

Results of previous studies suggest that bipolar disorder often can be misunderstood or misdiagnosed in primary care settings (JAMA 2005;293:956-63; J. Clin. Psychiatry 2003;64:53-9).

“Many [patients] get misdiagnosed with depression and get sent down an entirely wrong treatment path,” Ms. Smith said in an interview at the meeting, which was sponsored by the National Institute of Mental Health.

To evaluate family physicians' educational needs regarding this disorder, Ms. Smith and her colleagues mailed surveys to 900 family physicians in January 2009. The 77 respondents (a 9% response rate) rated their own preparedness regarding screening for bipolar disorder, discussion of comorbidities, evaluation of the phase of bipolar disorder based on symptoms, discussion of psychotherapy and pharmacologic options, and development of a treatment plan.

“By and large, the majority rated themselves as 'not very prepared' or 'somewhat prepared,'” said Ms. Smith, scientific director for a medical education company in Ramsey, N.J.

More than half felt this way when asked about their ability to assess for bipolar disorder using a screening tool or interviewing techniques (36 of 69 respondents, or 52%). Another 36% felt prepared and 12%, very prepared.

Fifty-three percent of 68 felt they were not very prepared or were only somewhat prepared for discussion of comorbidities, 41% were prepared, and 6% were very prepared.

Regarding diagnosis of the phase of the disorder based on symptoms, 51% of 69 physicians felt not very or somewhat prepared, 39% felt prepared, and 10% felt very prepared.

Respondents rated themselves as less prepared to discuss psychotherapy options; Sixty-four percent of 67 physicians said they were not very prepared or were only somewhat prepared. Another 30% said they were prepared and only 6% were very prepared.

More family physicians said they were prepared or very prepared to discuss pharmacologic treatments: In all, 58% were not very prepared or only somewhat prepared, 33% were prepared, and 9% were very prepared.

Primary care physicians play an integral role in the initiation of treatment, especially when there are no psychiatrists available for referral, Ms. Smith said. She acknowledged that learning more about bipolar disorder “is a challenge for primary care physicians, given their [time] constraints.”

Along with Dr. Jennifer Payne of the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, the lead investigator of the study, Ms. Smith and others developed a free online course. Dr. Payne is the course director.

The survey and online course are supported by a grant from Eli Lilly & Co. Ms. Smith said she had no relevant disclosures. Dr. Payne is a consultant for AstraZeneca and Wyeth and receives honoraria from Wyeth.

To take the free online course, go to www.bipolarCME.com

Most of those surveyed rated themselves as inadequately prepared to diagnose bipolar disorder.

Source DR. SMITH

Young adults who report sleeping fewer hours per night on average than do their counterparts are at elevated risk for persistent or new-onset psychological distress, according to results of a large, prospective cohort study.

Researchers found a linear correlation – a 14% greater risk for higher psychological distress for each hour slept fewer than 8, on average, per night – after they controlled for possible confounders. Sleeping 8-9 hours per night is recommended.

A total of 19,648 Australians (aged 17-24 years) reported their sleep hours for the previous month in a survey of registered drivers. Researchers found almost one-third (32.5%) had high baseline levels of psychological distress (defined as a score greater than 21 on the K10 (Kessler Psychological Distress Scale), a 10-item instrument that screens for feeling “tired out for no reason,” nervous, hopeless, restless, or depressed during the previous 4 weeks.

Psychological distress was most acute among the fewer than 2% of young adults who reported sleeping an average 5 hours or fewer per night, representing a group that might benefit the most from an intervention to improve their sleep routine. Another 18% reported sleeping an average 7 hours or fewer per night, and 30% reported sleeping 7-8 hours each night.

The full findings of the study were published in the September issue of the journal Sleep (2010;33:1139-45).

Lead researcher Dr. Nicholas Glozier and his associates also resurveyed a random sample of 2,937 respondents 12-18 months later. They found that high levels of distress persisted for 32% of the 945 who were initially distressed at baseline. In addition, 12% of those with no initial elevated distress (239 of 1992 respondents) had new-onset distress 1 year later, reported Dr. Glozier, who is on the psychological medicine faculty at the Brain and Mind Research Institute at the University of Sydney.

Again, a linear association was found between shorter sleep duration and likelihood for onset of psychological distress (relative risk, 1.12). Risk was most pronounced among those reporting an average 5 hours or fewer of sleep (RR, 3.25), compared with other participants.

This is the first prospective study to link shorter sleep duration in young adults with increased psychological distress, the researchers noted. Interestingly, there was no increased risk of psychological distress at any time in the study among those who reported sleeping an average 9 hours or more per night.

Based on these findings, clinicians could potentially identify young adults who are at elevated risk for persistent or new onset psychological distress by asking about sleep duration. Also, because young adulthood is a time when elevated psychological distress could develop into depression and many other psychiatric conditions, short sleep duration could be an important marker for early intervention, the authors wrote.

The authors acknowledged the difficulty associated with any populationwide effort to improve sleep (such as reducing late-night television viewing, computer gaming, and Internet use). Instead, they recommend that clinicians identify and focus their efforts on young adults who are at highest risk: those who report current distress or extremely short sleep duration. Other researchers demonstrated an association between short sleep duration and later bedtimes with depressed mood and suicidal ideation among adolescents (Sleep 2010;33:97-106).

High psychological distress was more common among females (40%, compared with 28% of males). It was also higher among those who reported unemployment (33% vs. 28% of those employed); drug use (45% vs. 32%); harmful alcohol use (38% vs. 32%); high sensation-seeking behavior (44% vs. 22%), and recent deliberate self-harm (70% vs. 31%). The researchers controlled for these potential confounders in the study.

Predictors of persistent distress included initial symptom severity, older age, and recent attempts at self-harm. The authors termed presence of elevated distress at baseline and follow-up as “persistent,” but said that taking measurements at only two time points is a potential limitation. In addition, the cohort was derived from driving registration records and might not be representative of the entire population of 17- to 24-year-olds.

There was no industry support for the study. Dr. Glozier is a member of the Sanofi-Aventis advisory board and is a speaker for CSL Laboratories. Dr. Ian Hickie, one of the investigators, formerly served as chief executive officer and clinical adviser for Beyondblue, the Australian National Depression Initiative, and has led projects supported by numerous drug industry partners. The other authors reported no relevant disclosures.

Young adults who report sleeping fewer hours per night on average than do their counterparts are at elevated risk for persistent or new-onset psychological distress, according to results of a large, prospective cohort study.

Researchers found a linear correlation – a 14% greater risk for higher psychological distress for each hour slept fewer than 8, on average, per night – after they controlled for possible confounders. Sleeping 8-9 hours per night is recommended.

A total of 19,648 Australians (aged 17-24 years) reported their sleep hours for the previous month in a survey of registered drivers. Researchers found almost one-third (32.5%) had high baseline levels of psychological distress (defined as a score greater than 21 on the K10 (Kessler Psychological Distress Scale), a 10-item instrument that screens for feeling “tired out for no reason,” nervous, hopeless, restless, or depressed during the previous 4 weeks.

Psychological distress was most acute among the fewer than 2% of young adults who reported sleeping an average 5 hours or fewer per night, representing a group that might benefit the most from an intervention to improve their sleep routine. Another 18% reported sleeping an average 7 hours or fewer per night, and 30% reported sleeping 7-8 hours each night.

The full findings of the study were published in the September issue of the journal Sleep (2010;33:1139-45).

Lead researcher Dr. Nicholas Glozier and his associates also resurveyed a random sample of 2,937 respondents 12-18 months later. They found that high levels of distress persisted for 32% of the 945 who were initially distressed at baseline. In addition, 12% of those with no initial elevated distress (239 of 1992 respondents) had new-onset distress 1 year later, reported Dr. Glozier, who is on the psychological medicine faculty at the Brain and Mind Research Institute at the University of Sydney.

Again, a linear association was found between shorter sleep duration and likelihood for onset of psychological distress (relative risk, 1.12). Risk was most pronounced among those reporting an average 5 hours or fewer of sleep (RR, 3.25), compared with other participants.

This is the first prospective study to link shorter sleep duration in young adults with increased psychological distress, the researchers noted. Interestingly, there was no increased risk of psychological distress at any time in the study among those who reported sleeping an average 9 hours or more per night.

Based on these findings, clinicians could potentially identify young adults who are at elevated risk for persistent or new onset psychological distress by asking about sleep duration. Also, because young adulthood is a time when elevated psychological distress could develop into depression and many other psychiatric conditions, short sleep duration could be an important marker for early intervention, the authors wrote.

The authors acknowledged the difficulty associated with any populationwide effort to improve sleep (such as reducing late-night television viewing, computer gaming, and Internet use). Instead, they recommend that clinicians identify and focus their efforts on young adults who are at highest risk: those who report current distress or extremely short sleep duration. Other researchers demonstrated an association between short sleep duration and later bedtimes with depressed mood and suicidal ideation among adolescents (Sleep 2010;33:97-106).

High psychological distress was more common among females (40%, compared with 28% of males). It was also higher among those who reported unemployment (33% vs. 28% of those employed); drug use (45% vs. 32%); harmful alcohol use (38% vs. 32%); high sensation-seeking behavior (44% vs. 22%), and recent deliberate self-harm (70% vs. 31%). The researchers controlled for these potential confounders in the study.

Predictors of persistent distress included initial symptom severity, older age, and recent attempts at self-harm. The authors termed presence of elevated distress at baseline and follow-up as “persistent,” but said that taking measurements at only two time points is a potential limitation. In addition, the cohort was derived from driving registration records and might not be representative of the entire population of 17- to 24-year-olds.

There was no industry support for the study. Dr. Glozier is a member of the Sanofi-Aventis advisory board and is a speaker for CSL Laboratories. Dr. Ian Hickie, one of the investigators, formerly served as chief executive officer and clinical adviser for Beyondblue, the Australian National Depression Initiative, and has led projects supported by numerous drug industry partners. The other authors reported no relevant disclosures.

Young adults who report sleeping fewer hours per night on average than do their counterparts are at elevated risk for persistent or new-onset psychological distress, according to results of a large, prospective cohort study.

Researchers found a linear correlation – a 14% greater risk for higher psychological distress for each hour slept fewer than 8, on average, per night – after they controlled for possible confounders. Sleeping 8-9 hours per night is recommended.

A total of 19,648 Australians (aged 17-24 years) reported their sleep hours for the previous month in a survey of registered drivers. Researchers found almost one-third (32.5%) had high baseline levels of psychological distress (defined as a score greater than 21 on the K10 (Kessler Psychological Distress Scale), a 10-item instrument that screens for feeling “tired out for no reason,” nervous, hopeless, restless, or depressed during the previous 4 weeks.

Psychological distress was most acute among the fewer than 2% of young adults who reported sleeping an average 5 hours or fewer per night, representing a group that might benefit the most from an intervention to improve their sleep routine. Another 18% reported sleeping an average 7 hours or fewer per night, and 30% reported sleeping 7-8 hours each night.

The full findings of the study were published in the September issue of the journal Sleep (2010;33:1139-45).

Lead researcher Dr. Nicholas Glozier and his associates also resurveyed a random sample of 2,937 respondents 12-18 months later. They found that high levels of distress persisted for 32% of the 945 who were initially distressed at baseline. In addition, 12% of those with no initial elevated distress (239 of 1992 respondents) had new-onset distress 1 year later, reported Dr. Glozier, who is on the psychological medicine faculty at the Brain and Mind Research Institute at the University of Sydney.

Again, a linear association was found between shorter sleep duration and likelihood for onset of psychological distress (relative risk, 1.12). Risk was most pronounced among those reporting an average 5 hours or fewer of sleep (RR, 3.25), compared with other participants.

This is the first prospective study to link shorter sleep duration in young adults with increased psychological distress, the researchers noted. Interestingly, there was no increased risk of psychological distress at any time in the study among those who reported sleeping an average 9 hours or more per night.

Based on these findings, clinicians could potentially identify young adults who are at elevated risk for persistent or new onset psychological distress by asking about sleep duration. Also, because young adulthood is a time when elevated psychological distress could develop into depression and many other psychiatric conditions, short sleep duration could be an important marker for early intervention, the authors wrote.

The authors acknowledged the difficulty associated with any populationwide effort to improve sleep (such as reducing late-night television viewing, computer gaming, and Internet use). Instead, they recommend that clinicians identify and focus their efforts on young adults who are at highest risk: those who report current distress or extremely short sleep duration. Other researchers demonstrated an association between short sleep duration and later bedtimes with depressed mood and suicidal ideation among adolescents (Sleep 2010;33:97-106).

High psychological distress was more common among females (40%, compared with 28% of males). It was also higher among those who reported unemployment (33% vs. 28% of those employed); drug use (45% vs. 32%); harmful alcohol use (38% vs. 32%); high sensation-seeking behavior (44% vs. 22%), and recent deliberate self-harm (70% vs. 31%). The researchers controlled for these potential confounders in the study.

Predictors of persistent distress included initial symptom severity, older age, and recent attempts at self-harm. The authors termed presence of elevated distress at baseline and follow-up as “persistent,” but said that taking measurements at only two time points is a potential limitation. In addition, the cohort was derived from driving registration records and might not be representative of the entire population of 17- to 24-year-olds.

There was no industry support for the study. Dr. Glozier is a member of the Sanofi-Aventis advisory board and is a speaker for CSL Laboratories. Dr. Ian Hickie, one of the investigators, formerly served as chief executive officer and clinical adviser for Beyondblue, the Australian National Depression Initiative, and has led projects supported by numerous drug industry partners. The other authors reported no relevant disclosures.

NAPLES, FLA. — Many women with hirsutism have already removed their excess, unwanted hair before they present. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, to identify important medical conditions associated with excess hair growth.

“Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings.” Accurate diagnosis also optimizes dermatology treatment. “Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result],” Dr. Olsen said at the meeting.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum levels of dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. “You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone.” In addition, she added, “I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases.”

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

“One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease,” Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said.

To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls.

These girls also will have advanced bone age but premature closure of epiphyses, “so, ultimately, they have short adult stature,” she said. In adult women, it is important to include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. “If someone is suddenly developing hirsutism, that should be in the back of your mind.”

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the U.S. Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair.

“It decreases the rate of hair growth and amount of shaving a woman has to do,” Dr. Olsen said. “It's a decrease in the rate of hair growth only” and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, FLA. — Many women with hirsutism have already removed their excess, unwanted hair before they present. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, to identify important medical conditions associated with excess hair growth.

“Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings.” Accurate diagnosis also optimizes dermatology treatment. “Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result],” Dr. Olsen said at the meeting.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum levels of dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. “You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone.” In addition, she added, “I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases.”

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

“One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease,” Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said.

To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls.

These girls also will have advanced bone age but premature closure of epiphyses, “so, ultimately, they have short adult stature,” she said. In adult women, it is important to include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. “If someone is suddenly developing hirsutism, that should be in the back of your mind.”

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the U.S. Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair.

“It decreases the rate of hair growth and amount of shaving a woman has to do,” Dr. Olsen said. “It's a decrease in the rate of hair growth only” and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, FLA. — Many women with hirsutism have already removed their excess, unwanted hair before they present. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, to identify important medical conditions associated with excess hair growth.

“Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings.” Accurate diagnosis also optimizes dermatology treatment. “Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result],” Dr. Olsen said at the meeting.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum levels of dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. “You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone.” In addition, she added, “I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases.”

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

“One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease,” Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said.

To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls.

These girls also will have advanced bone age but premature closure of epiphyses, “so, ultimately, they have short adult stature,” she said. In adult women, it is important to include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. “If someone is suddenly developing hirsutism, that should be in the back of your mind.”

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the U.S. Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair.

“It decreases the rate of hair growth and amount of shaving a woman has to do,” Dr. Olsen said. “It's a decrease in the rate of hair growth only” and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

MIAMI — Pediatricians are essential to ensure the successful transition of a chronically ill pediatric patient to adult care providers, according to Dr. Daniel V. Schidlow.

Prepare and encourage the patient and family, establish a “mirror image” adult care team and work in tandem with them, and recognize when the time is right for the patient to leave your care, he said.

Although Dr. Schidlow is a pediatric pulmonologist, many of the themes for transitioning are universal to all chronic conditions, especially those with a genetic basis, he said. For example, there is no prescribed moment to transition, such as graduation from high school or college. The timing should be tailored to the individual patient.

“The transition should be smooth, change should occur as part of the process, and it should not be imposed,” said Dr. Schidlow of St. Christopher's Hospital for Children, Philadelphia. “The transition happens when the patient, family, and everyone else are ready.”

The numbers of adults with chronic diseases are increasing steadily, he said. “Cystic fibrosis is one of my specialties.” In 1984, there were no adult programs for cystic fibrosis. Today, only centers with an adult component are accredited by the Cystic Fibrosis Foundation.

“Adults with chronic diseases that started in childhood, especially those with genetic diseases, need a different environment for care,” said Dr. Schidlow, who is also professor and chair of the department of pediatrics at Drexel University, Philadelphia.

Pediatricians tend to communicate more with parents than children, have a developmental focus, and address school performance, sports, and other social aspects of childhood, he said. In contrast, adult health care is more patient driven and patient focused. The social issues also shift toward work, relationships, sexuality, and reproduction, among others.

Pediatrician support for the transition is crucial to its success. Speak with the family and advise them “the time is quickly coming for them to start thinking about going to an adult caregiver,” Dr. Schidlow said at the meeting.

The transition process typically occurs over the course of a year, during which time the pediatric and adult care teams see the patient together. “By the time the patients leave us and go to the adult center, they already feel very comfortable,” he said.

Also important to a smooth transition are recognition that independence and self-sufficiency are desirable goals for adolescents with “pediatric diseases,” that patients have the ability to adapt to new health care systems, and that given the proper conditions, adult caregivers are able to provide the quality of care these individuals need, Dr. Schidlow said.

“Even today, after many years of addressing these issues, there are obstacles that have not been surmounted. One of the obstacles is the relative lack of expertise of adult caregivers in some of the pediatric conditions, particularly some genetic disorders,” he said in a video interview following his presentation.

Transitioning of care is not appropriate for everyone. Patients who are medically unstable, nearing death, or awaiting lung transplantation, for example, are not good candidates, he said.

Disclosures: Dr. Schidlow said he had no relevant financial disclosures.

For more of the video interview with Dr. Schidlow, including why many of his patients still keep in touch after making a successful transition, visit www.youtube.com/watch?v=-NIdVfxZky

MIAMI — Pediatricians are essential to ensure the successful transition of a chronically ill pediatric patient to adult care providers, according to Dr. Daniel V. Schidlow.

Prepare and encourage the patient and family, establish a “mirror image” adult care team and work in tandem with them, and recognize when the time is right for the patient to leave your care, he said.

Although Dr. Schidlow is a pediatric pulmonologist, many of the themes for transitioning are universal to all chronic conditions, especially those with a genetic basis, he said. For example, there is no prescribed moment to transition, such as graduation from high school or college. The timing should be tailored to the individual patient.

“The transition should be smooth, change should occur as part of the process, and it should not be imposed,” said Dr. Schidlow of St. Christopher's Hospital for Children, Philadelphia. “The transition happens when the patient, family, and everyone else are ready.”

The numbers of adults with chronic diseases are increasing steadily, he said. “Cystic fibrosis is one of my specialties.” In 1984, there were no adult programs for cystic fibrosis. Today, only centers with an adult component are accredited by the Cystic Fibrosis Foundation.

“Adults with chronic diseases that started in childhood, especially those with genetic diseases, need a different environment for care,” said Dr. Schidlow, who is also professor and chair of the department of pediatrics at Drexel University, Philadelphia.

Pediatricians tend to communicate more with parents than children, have a developmental focus, and address school performance, sports, and other social aspects of childhood, he said. In contrast, adult health care is more patient driven and patient focused. The social issues also shift toward work, relationships, sexuality, and reproduction, among others.

Pediatrician support for the transition is crucial to its success. Speak with the family and advise them “the time is quickly coming for them to start thinking about going to an adult caregiver,” Dr. Schidlow said at the meeting.

The transition process typically occurs over the course of a year, during which time the pediatric and adult care teams see the patient together. “By the time the patients leave us and go to the adult center, they already feel very comfortable,” he said.

Also important to a smooth transition are recognition that independence and self-sufficiency are desirable goals for adolescents with “pediatric diseases,” that patients have the ability to adapt to new health care systems, and that given the proper conditions, adult caregivers are able to provide the quality of care these individuals need, Dr. Schidlow said.

“Even today, after many years of addressing these issues, there are obstacles that have not been surmounted. One of the obstacles is the relative lack of expertise of adult caregivers in some of the pediatric conditions, particularly some genetic disorders,” he said in a video interview following his presentation.

Transitioning of care is not appropriate for everyone. Patients who are medically unstable, nearing death, or awaiting lung transplantation, for example, are not good candidates, he said.

Disclosures: Dr. Schidlow said he had no relevant financial disclosures.

For more of the video interview with Dr. Schidlow, including why many of his patients still keep in touch after making a successful transition, visit www.youtube.com/watch?v=-NIdVfxZky

MIAMI — Pediatricians are essential to ensure the successful transition of a chronically ill pediatric patient to adult care providers, according to Dr. Daniel V. Schidlow.

Prepare and encourage the patient and family, establish a “mirror image” adult care team and work in tandem with them, and recognize when the time is right for the patient to leave your care, he said.

Although Dr. Schidlow is a pediatric pulmonologist, many of the themes for transitioning are universal to all chronic conditions, especially those with a genetic basis, he said. For example, there is no prescribed moment to transition, such as graduation from high school or college. The timing should be tailored to the individual patient.

“The transition should be smooth, change should occur as part of the process, and it should not be imposed,” said Dr. Schidlow of St. Christopher's Hospital for Children, Philadelphia. “The transition happens when the patient, family, and everyone else are ready.”

The numbers of adults with chronic diseases are increasing steadily, he said. “Cystic fibrosis is one of my specialties.” In 1984, there were no adult programs for cystic fibrosis. Today, only centers with an adult component are accredited by the Cystic Fibrosis Foundation.

“Adults with chronic diseases that started in childhood, especially those with genetic diseases, need a different environment for care,” said Dr. Schidlow, who is also professor and chair of the department of pediatrics at Drexel University, Philadelphia.

Pediatricians tend to communicate more with parents than children, have a developmental focus, and address school performance, sports, and other social aspects of childhood, he said. In contrast, adult health care is more patient driven and patient focused. The social issues also shift toward work, relationships, sexuality, and reproduction, among others.

Pediatrician support for the transition is crucial to its success. Speak with the family and advise them “the time is quickly coming for them to start thinking about going to an adult caregiver,” Dr. Schidlow said at the meeting.

The transition process typically occurs over the course of a year, during which time the pediatric and adult care teams see the patient together. “By the time the patients leave us and go to the adult center, they already feel very comfortable,” he said.

Also important to a smooth transition are recognition that independence and self-sufficiency are desirable goals for adolescents with “pediatric diseases,” that patients have the ability to adapt to new health care systems, and that given the proper conditions, adult caregivers are able to provide the quality of care these individuals need, Dr. Schidlow said.

“Even today, after many years of addressing these issues, there are obstacles that have not been surmounted. One of the obstacles is the relative lack of expertise of adult caregivers in some of the pediatric conditions, particularly some genetic disorders,” he said in a video interview following his presentation.

Transitioning of care is not appropriate for everyone. Patients who are medically unstable, nearing death, or awaiting lung transplantation, for example, are not good candidates, he said.

Disclosures: Dr. Schidlow said he had no relevant financial disclosures.

For more of the video interview with Dr. Schidlow, including why many of his patients still keep in touch after making a successful transition, visit www.youtube.com/watch?v=-NIdVfxZky

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

Boca Raton, Fla. — A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

The Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) also correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

The online version 'is accurate, trustworthy, and convenient.'

Source Dr. zimmerman

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. They thought the information collected on the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said.

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the two CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement. With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, Dr. Zimmerman said.

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

Boca Raton, Fla. — A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

The Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) also correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

The online version 'is accurate, trustworthy, and convenient.'

Source Dr. zimmerman

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. They thought the information collected on the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said.

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the two CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement. With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, Dr. Zimmerman said.

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

Boca Raton, Fla. — A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

The Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) also correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

The online version 'is accurate, trustworthy, and convenient.'

Source Dr. zimmerman

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. They thought the information collected on the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said.

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the two CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement. With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, Dr. Zimmerman said.

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

BOCA RATON, FLA. – A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

In addition, the Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. “Patients trust it, interestingly. They found it is as trustworthy as paper questionnaires.” Patients thought the information collected via the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said. “I did not expect that kind of preference.”

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement.

With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, according to Dr. Zimmerman.

The study did not have a funding source.

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

BOCA RATON, FLA. – A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

In addition, the Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. “Patients trust it, interestingly. They found it is as trustworthy as paper questionnaires.” Patients thought the information collected via the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said. “I did not expect that kind of preference.”

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement.

With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, according to Dr. Zimmerman.

The study did not have a funding source.

Major Finding: 100% of patients preferred an online vs. paper version of CUDOS. Mean score of 19.6 online was nearly identical to 19.0 on the previously validated paper CUDOS.

Data Source: Study of 46 depressed outpatients who completed both versions of CUDOS. Researchers compared scores with independent clinician ratings of depression.

Disclosures: Dr. Zimmerman said he had no relevant disclosures.

BOCA RATON, FLA. – A brief online depression assessment tool is as valid as a paper-and-pencil version of the questionnaire, a study of 46 psychiatric outpatients showed.

In addition, the Web version of the Clinically Useful Depression Outcomes Scale (CUDOS) correlated 89% or more with blinded clinician ratings of depression.

Patients were given the Web address (www.outcometracker.org

All patients preferred the Internet version to the paper questionnaire, Dr. Mark Zimmerman said at a poster presentation. “Patients trust it, interestingly. They found it is as trustworthy as paper questionnaires.” Patients thought the information collected via the free Web site was more accurate (38% vs. 0%) as well as safer and more secure (52% vs. 5%), compared with paper, Dr. Zimmerman said. “I did not expect that kind of preference.”

The conventional CUDOS takes less than 3 minutes to complete and about 15 seconds to score. Dr. Zimmerman said both versions are clinically useful because they cover all DSM-IV symptoms of major depressive disorder.

A greater percentage of patients reported that the online version took less time to complete (59%), compared with 7% who reported that the paper version was quicker. The remaining 34% said completion time was about the same.

“So it is accurate, trustworthy, and convenient,” said Dr. Zimmerman of the department of psychiatry and human behavior at Brown University and director of outpatient psychiatry at Rhode Island Hospital, both in Providence.

The study included 11 men and 35 women (mean age, 44 years).

The 19.6 mean score on the Web version was nearly identical to the 19.0 mean score on the paper version. Agreement on remission status (based on a previously validated cutoff value of 20) was 91% between the CUDOS instruments.

Independent clinicians rated depression in each participant using the MADRS (Montgomery-Åsberg Depression Rating Scale), the CGI-S (Clinical Global Index–Severity) scale, and the GAF (Global Assessment of Functioning) scale. At baseline, patients had a middle level of depression severity, indicated by a mean MADRS score of 12.4 and CGI-S score of 1.3. The mean GAF score was 65.2.

Without valid, standardized instruments such as CUDOS, “assessment of outcome is not precise, and that could have clinical consequences.” For example, an individual patient might tell his psychiatrist he is feeling better, but he might have residual depression symptoms that CUDOS could detect and that otherwise would put him at risk of relapse.

On the other hand, a patient might tell his psychiatrist that he is not feeling better while the instrument indicates some symptom improvement.

With this information, a clinician might opt to adjust the patient's dosage instead of switching medications, for example, according to Dr. Zimmerman.

The study did not have a funding source.

Major Finding: Risk for suicide ideation and/or attempt was higher in young adolescents who report drinking alcohol as preteenagers (adjusted odds ratio 2.40), compared with self-reported nondrinkers. Risk remains significantly elevated when they are resurveyed as older adolescents (OR, 3.13), but not as adults (OR, 1.71).

Data Source: An initial and two follow-up surveys of 10,417 participants in the National Longitudinal Study of Adolescent Health

Disclosures: None was reported.

ORLANDO – Adolescents who start drinking alcohol before age 13 are at a significantly increased risk for suicide ideation and attempts, even when controlling for depression, psychiatric treatment, and other risk factors.

An emphasis on interventions to delay or prevent early alcohol initiation therefore could be beneficial, reported Monica H. Swahn, Ph.D., associate professor, Institute of Public Health, Georgia State University, Atlanta.

Compared with self-reported nondrinkers, risk for suicide ideation and/or attempt was higher in young adolescents who reported drinking alcohol as preteenagers (adjusted odds ratio, 2.40). Risk remained elevated when the same cohort was resurveyed as older teens (adjusted OR, 3.13), Dr. Swahn reported.

However, the risk for subsequent suicide was no longer significant when the same participants were surveyed as adults (OR, 1.71). Alcohol use, especially early alcohol use, may increase capacity for suicide behaviors. “Most of us talk about the inhibition, but there is also an indirect effect–alcohol can increase other risks.” Adverse effects on brain development and increased tolerance to pain are examples. Early initiation also might be an indicator of family dysfunction or poor coping strategies, Dr. Swahn said.

“Until recently, very little research has examined the role of early alcohol use initiation, prior to age 13, as a specific risk factor for suicide,” Dr. Swahn said.

To find out more, she and her associates conducted a secondary analysis of three prospective waves of data from the National Longitudinal Study of Adolescent Health. Of the total 10,417 participants, 13.8% reported drinking alcohol before the age of 13.

The first survey in 1995 included a nationally representative group of adolescents in grades 7 through 12; the next wave of data was collected the following year; and a third wave assessed the same group in 2008. Only participants who reported suicide ideation were asked about an attempt, so the two variables were combined.

The adolescent health study only includes self-reported data, a potential limitation of this study. No inclusion of any other circumstances around early alcohol use or suicidal behavior, as well as no consideration of changes in development or life circumstances, were other possible limitations, Dr. Swahn said.

Future study could examine vulnerable subgroups, such as those who lost friends or family to suicide or those who experienced childhood maltreatment. In addition, Dr. Swahn would like to explore any patterns by gender or race/ethnicity.

The American Foundation for Suicide Prevention provided a research grant for the study.

Major Finding: Risk for suicide ideation and/or attempt was higher in young adolescents who report drinking alcohol as preteenagers (adjusted odds ratio 2.40), compared with self-reported nondrinkers. Risk remains significantly elevated when they are resurveyed as older adolescents (OR, 3.13), but not as adults (OR, 1.71).

Data Source: An initial and two follow-up surveys of 10,417 participants in the National Longitudinal Study of Adolescent Health

Disclosures: None was reported.

ORLANDO – Adolescents who start drinking alcohol before age 13 are at a significantly increased risk for suicide ideation and attempts, even when controlling for depression, psychiatric treatment, and other risk factors.

An emphasis on interventions to delay or prevent early alcohol initiation therefore could be beneficial, reported Monica H. Swahn, Ph.D., associate professor, Institute of Public Health, Georgia State University, Atlanta.

Compared with self-reported nondrinkers, risk for suicide ideation and/or attempt was higher in young adolescents who reported drinking alcohol as preteenagers (adjusted odds ratio, 2.40). Risk remained elevated when the same cohort was resurveyed as older teens (adjusted OR, 3.13), Dr. Swahn reported.

However, the risk for subsequent suicide was no longer significant when the same participants were surveyed as adults (OR, 1.71). Alcohol use, especially early alcohol use, may increase capacity for suicide behaviors. “Most of us talk about the inhibition, but there is also an indirect effect–alcohol can increase other risks.” Adverse effects on brain development and increased tolerance to pain are examples. Early initiation also might be an indicator of family dysfunction or poor coping strategies, Dr. Swahn said.

“Until recently, very little research has examined the role of early alcohol use initiation, prior to age 13, as a specific risk factor for suicide,” Dr. Swahn said.

To find out more, she and her associates conducted a secondary analysis of three prospective waves of data from the National Longitudinal Study of Adolescent Health. Of the total 10,417 participants, 13.8% reported drinking alcohol before the age of 13.

The first survey in 1995 included a nationally representative group of adolescents in grades 7 through 12; the next wave of data was collected the following year; and a third wave assessed the same group in 2008. Only participants who reported suicide ideation were asked about an attempt, so the two variables were combined.

The adolescent health study only includes self-reported data, a potential limitation of this study. No inclusion of any other circumstances around early alcohol use or suicidal behavior, as well as no consideration of changes in development or life circumstances, were other possible limitations, Dr. Swahn said.

Future study could examine vulnerable subgroups, such as those who lost friends or family to suicide or those who experienced childhood maltreatment. In addition, Dr. Swahn would like to explore any patterns by gender or race/ethnicity.

The American Foundation for Suicide Prevention provided a research grant for the study.

Major Finding: Risk for suicide ideation and/or attempt was higher in young adolescents who report drinking alcohol as preteenagers (adjusted odds ratio 2.40), compared with self-reported nondrinkers. Risk remains significantly elevated when they are resurveyed as older adolescents (OR, 3.13), but not as adults (OR, 1.71).

Data Source: An initial and two follow-up surveys of 10,417 participants in the National Longitudinal Study of Adolescent Health

Disclosures: None was reported.

ORLANDO – Adolescents who start drinking alcohol before age 13 are at a significantly increased risk for suicide ideation and attempts, even when controlling for depression, psychiatric treatment, and other risk factors.

An emphasis on interventions to delay or prevent early alcohol initiation therefore could be beneficial, reported Monica H. Swahn, Ph.D., associate professor, Institute of Public Health, Georgia State University, Atlanta.

Compared with self-reported nondrinkers, risk for suicide ideation and/or attempt was higher in young adolescents who reported drinking alcohol as preteenagers (adjusted odds ratio, 2.40). Risk remained elevated when the same cohort was resurveyed as older teens (adjusted OR, 3.13), Dr. Swahn reported.

However, the risk for subsequent suicide was no longer significant when the same participants were surveyed as adults (OR, 1.71). Alcohol use, especially early alcohol use, may increase capacity for suicide behaviors. “Most of us talk about the inhibition, but there is also an indirect effect–alcohol can increase other risks.” Adverse effects on brain development and increased tolerance to pain are examples. Early initiation also might be an indicator of family dysfunction or poor coping strategies, Dr. Swahn said.

“Until recently, very little research has examined the role of early alcohol use initiation, prior to age 13, as a specific risk factor for suicide,” Dr. Swahn said.

To find out more, she and her associates conducted a secondary analysis of three prospective waves of data from the National Longitudinal Study of Adolescent Health. Of the total 10,417 participants, 13.8% reported drinking alcohol before the age of 13.

The first survey in 1995 included a nationally representative group of adolescents in grades 7 through 12; the next wave of data was collected the following year; and a third wave assessed the same group in 2008. Only participants who reported suicide ideation were asked about an attempt, so the two variables were combined.

The adolescent health study only includes self-reported data, a potential limitation of this study. No inclusion of any other circumstances around early alcohol use or suicidal behavior, as well as no consideration of changes in development or life circumstances, were other possible limitations, Dr. Swahn said.

Future study could examine vulnerable subgroups, such as those who lost friends or family to suicide or those who experienced childhood maltreatment. In addition, Dr. Swahn would like to explore any patterns by gender or race/ethnicity.

The American Foundation for Suicide Prevention provided a research grant for the study.

Major Finding: Relative risk of risperidone inefficacy is lower among pediatric patients (0.43), compared with adults (0.64).

Data Source: Meta-analysis of 30 studies with 872 pediatric patients and 2,655 adults.

Disclosures: Dr. Maayan said he has received research support from Eli Lilly and Pfizer. The current study had no funding source.

BOCA RATON, FLA. – The efficacy and tolerability of risperidone differ between pediatric and adult patients, according to a meta-analysis of 32 double-blind, placebo-controlled trials.

For pediatric prescribers of risperidone, there is good news, mixed news, and not-so-good news, Dr. Lawrence A. Maayan said.

“The good news is study-defined efficacy: Treatment did better than placebo for both children and adults, but significantly better in children,” said Dr. Maayan, a child and adolescent psychiatrist at the Nathan S. Kline Institute for Psychiatric Research at New York University in Orangeburg, N.Y.

Of the studies that included data on efficacy, Dr. Maayan and his colleagues compared 12 studies of 872 pediatric patients with 18 such trials of 2,655 adults. They found that a relative risk of inefficacy was lower among children and adolescents (0.43), compared with adults (0.64). The difference was most pronounced in schizophrenia, which favored pediatric patients (RR, 0.34), compared with adults (RR, 0.62).

“By this metric, risperidone works better in children than in adults. It is reassuring to a pediatric prescriber,” Dr. Maayan said in an interview at his poster. Risperidone is manufactured by Ortho-McNeil-Janssen.

The meta-analysis also included populations with bipolar disorder, subaverage intelligence/disruptive behavior disorders, posttraumatic stress disorder, autism/pervasive developmental disorder, and Alzheimer's dementia. The 32 studies comprised 1,184 children and adolescents (72% male, 65% white) and 3,909 adults (53% male, 85% white).

There was some mixed news regarding adverse events, Dr. Maayan said. For example, “children and adults did about equally” with discontinuation. A total of 26 studies assessed all-cause discontinuation and discontinuation because of inefficacy or intolerability/side effects.

There were no age-group differences in all-cause discontinuation between pediatric and adult patients, Dr. Maayan said. Although pediatric patients had a lower risk (RR, 0.60) compared with adults (RR, 0.77), the magnitude of the difference between risperidone and placebo groups was not statistically different between age groups, “which is reassuring.”

Pediatric patients also had a lower risk for discontinuation because of treatment inefficacy (RR, 0.30), compared with adults (RR, 0.52), Dr. Maayan said. “Children were able to continue [risperidone] just as well as adults.”

However, children were more likely to report at least one adverse event during risperidone treatment (RR, 1.30), compared with adults (RR, 1.01).

“The not-so-good news was raw weight gain: It was about the same in children as in adults,” Dr. Maayan said. “Two kilograms in a 40-year-old is different than a 2-kg gain in a 10-year-old.”

Dr. Maayan and his associates assessed weight gain as a percentage of baseline body weight. “The kids gained about three times as much.” Weight gain was 5.7% for children, vs. 1.5% for adults, a significant difference.

Counsel and talk to patients and families about this increased risk of weight gain with risperidone treatment as part of a full disclosure of benefits and risks, Dr. Maayan advised.

Major Finding: Relative risk of risperidone inefficacy is lower among pediatric patients (0.43), compared with adults (0.64).

Data Source: Meta-analysis of 30 studies with 872 pediatric patients and 2,655 adults.

Disclosures: Dr. Maayan said he has received research support from Eli Lilly and Pfizer. The current study had no funding source.

BOCA RATON, FLA. – The efficacy and tolerability of risperidone differ between pediatric and adult patients, according to a meta-analysis of 32 double-blind, placebo-controlled trials.

For pediatric prescribers of risperidone, there is good news, mixed news, and not-so-good news, Dr. Lawrence A. Maayan said.

“The good news is study-defined efficacy: Treatment did better than placebo for both children and adults, but significantly better in children,” said Dr. Maayan, a child and adolescent psychiatrist at the Nathan S. Kline Institute for Psychiatric Research at New York University in Orangeburg, N.Y.

Of the studies that included data on efficacy, Dr. Maayan and his colleagues compared 12 studies of 872 pediatric patients with 18 such trials of 2,655 adults. They found that a relative risk of inefficacy was lower among children and adolescents (0.43), compared with adults (0.64). The difference was most pronounced in schizophrenia, which favored pediatric patients (RR, 0.34), compared with adults (RR, 0.62).

“By this metric, risperidone works better in children than in adults. It is reassuring to a pediatric prescriber,” Dr. Maayan said in an interview at his poster. Risperidone is manufactured by Ortho-McNeil-Janssen.

The meta-analysis also included populations with bipolar disorder, subaverage intelligence/disruptive behavior disorders, posttraumatic stress disorder, autism/pervasive developmental disorder, and Alzheimer's dementia. The 32 studies comprised 1,184 children and adolescents (72% male, 65% white) and 3,909 adults (53% male, 85% white).

There was some mixed news regarding adverse events, Dr. Maayan said. For example, “children and adults did about equally” with discontinuation. A total of 26 studies assessed all-cause discontinuation and discontinuation because of inefficacy or intolerability/side effects.

There were no age-group differences in all-cause discontinuation between pediatric and adult patients, Dr. Maayan said. Although pediatric patients had a lower risk (RR, 0.60) compared with adults (RR, 0.77), the magnitude of the difference between risperidone and placebo groups was not statistically different between age groups, “which is reassuring.”

Pediatric patients also had a lower risk for discontinuation because of treatment inefficacy (RR, 0.30), compared with adults (RR, 0.52), Dr. Maayan said. “Children were able to continue [risperidone] just as well as adults.”

However, children were more likely to report at least one adverse event during risperidone treatment (RR, 1.30), compared with adults (RR, 1.01).

“The not-so-good news was raw weight gain: It was about the same in children as in adults,” Dr. Maayan said. “Two kilograms in a 40-year-old is different than a 2-kg gain in a 10-year-old.”

Dr. Maayan and his associates assessed weight gain as a percentage of baseline body weight. “The kids gained about three times as much.” Weight gain was 5.7% for children, vs. 1.5% for adults, a significant difference.

Counsel and talk to patients and families about this increased risk of weight gain with risperidone treatment as part of a full disclosure of benefits and risks, Dr. Maayan advised.

Major Finding: Relative risk of risperidone inefficacy is lower among pediatric patients (0.43), compared with adults (0.64).

Data Source: Meta-analysis of 30 studies with 872 pediatric patients and 2,655 adults.

Disclosures: Dr. Maayan said he has received research support from Eli Lilly and Pfizer. The current study had no funding source.

BOCA RATON, FLA. – The efficacy and tolerability of risperidone differ between pediatric and adult patients, according to a meta-analysis of 32 double-blind, placebo-controlled trials.

For pediatric prescribers of risperidone, there is good news, mixed news, and not-so-good news, Dr. Lawrence A. Maayan said.

“The good news is study-defined efficacy: Treatment did better than placebo for both children and adults, but significantly better in children,” said Dr. Maayan, a child and adolescent psychiatrist at the Nathan S. Kline Institute for Psychiatric Research at New York University in Orangeburg, N.Y.

Of the studies that included data on efficacy, Dr. Maayan and his colleagues compared 12 studies of 872 pediatric patients with 18 such trials of 2,655 adults. They found that a relative risk of inefficacy was lower among children and adolescents (0.43), compared with adults (0.64). The difference was most pronounced in schizophrenia, which favored pediatric patients (RR, 0.34), compared with adults (RR, 0.62).

“By this metric, risperidone works better in children than in adults. It is reassuring to a pediatric prescriber,” Dr. Maayan said in an interview at his poster. Risperidone is manufactured by Ortho-McNeil-Janssen.

The meta-analysis also included populations with bipolar disorder, subaverage intelligence/disruptive behavior disorders, posttraumatic stress disorder, autism/pervasive developmental disorder, and Alzheimer's dementia. The 32 studies comprised 1,184 children and adolescents (72% male, 65% white) and 3,909 adults (53% male, 85% white).

There was some mixed news regarding adverse events, Dr. Maayan said. For example, “children and adults did about equally” with discontinuation. A total of 26 studies assessed all-cause discontinuation and discontinuation because of inefficacy or intolerability/side effects.

There were no age-group differences in all-cause discontinuation between pediatric and adult patients, Dr. Maayan said. Although pediatric patients had a lower risk (RR, 0.60) compared with adults (RR, 0.77), the magnitude of the difference between risperidone and placebo groups was not statistically different between age groups, “which is reassuring.”

Pediatric patients also had a lower risk for discontinuation because of treatment inefficacy (RR, 0.30), compared with adults (RR, 0.52), Dr. Maayan said. “Children were able to continue [risperidone] just as well as adults.”

However, children were more likely to report at least one adverse event during risperidone treatment (RR, 1.30), compared with adults (RR, 1.01).

“The not-so-good news was raw weight gain: It was about the same in children as in adults,” Dr. Maayan said. “Two kilograms in a 40-year-old is different than a 2-kg gain in a 10-year-old.”

Dr. Maayan and his associates assessed weight gain as a percentage of baseline body weight. “The kids gained about three times as much.” Weight gain was 5.7% for children, vs. 1.5% for adults, a significant difference.

Counsel and talk to patients and families about this increased risk of weight gain with risperidone treatment as part of a full disclosure of benefits and risks, Dr. Maayan advised.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. — Many women with hirsutism have already removed their excess, unwanted hair before they present to dermatology. Look beyond the shaving, bleaching, plucking, and waxing, Dr. Elise A. Olsen said, because dermatologists play an important role in identification of important medical conditions associated with excess hair growth.

"Patients seen for the cosmetic treatment of hirsutism provide an opportunity to screen for [other] common findings." Accurate diagnosis also optimizes dermatology treatment. "Most of your patients with hirsutism will be coming in for laser hair removal. Evaluation for hirsutism will affect your [result]," Dr. Olsen said at the annual meeting of the Florida Society of Dermatology & Dermatologic Surgeons.

Polycystic ovarian syndrome, adrenal abnormalities, and drug reactions are important considerations in a differential diagnosis. Rule out these and other causes of hirsutism, as well as acromegaly and premature ovarian failure, Dr. Olsen said.

Hirsutism is a common problem that affects at least 5% of the female population, said Dr. Olsen, director of the Duke Dermatopharmacology Study Center and professor of dermatology at Duke University Medical Center in Durham, N.C.

Begin your evaluation with patient and family history. Ask about history of menses, acne, and how often the woman removes unwanted hair. Note affected anatomic sites during your physical examination, and use the Ferriman-Gallwey hirsutism index to score results, Dr. Olsen said. Also perform a pelvic examination and order ultrasound if you suspect a tumor or other abnormality.

Measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione, prolactin, and sex-hormone–binding globulin (SHBG) can facilitate diagnosis. Other helpful laboratory assays include luteinizing hormone/follicle stimulating hormone (LH/FSH) levels, a glucose tolerance test with insulin levels, and a fasting lipid panel.

Simple blood work includes a check of testosterone levels, Dr. Olsen said. "You will catch 40% [of hyperandrogenemia in hirsutism] with elevated testosterone alone and 60% with elevated free testosterone." In addition, she added, "I have started to do DHT or dihydrotestosterone because it can catch idiopathic cases."

Polycystic ovarian syndrome (PCOS) affects an estimated 3%-11% of women of reproductive age. Keep in mind that Rotterdam consensus criteria do not apply to adolescent girls, women on oral contraceptive pills, or postmenopausal women, Dr. Olsen said.

"One of the most important things I will talk about is that 50%-60% of these women with PCOS have insulin resistance. They have a three to seven times increased risk of type 2 diabetes, decreased fertility, and increased risk of cardiovascular disease," Dr. Olsen said. Risk of endometrial cancer is also elevated.

Part of ruling in PCOS is ruling out congenital adrenal hyperplasia, which can be challenging because many symptoms overlap, Dr. Olsen said. To diagnose congenital adrenal hyperplasia, look for premature pubarche with early pubic hair, cystic acne, and accelerated growth in girls. These girls also will have advanced bone age but premature closure of epiphyses, "so, ultimately, they have short adult stature." In adult women, include amenorrhea, anovulation, oligomenorrhea, and infertility in your differential diagnosis.

Tumors that cause hirsutism are rare, Dr. Olsen said. "If someone is suddenly developing hirsutism, that should be in the back of your mind."

Not surprisingly, androgen medications can cause excess hair growth in women. Danazol (Danocrine, Sanofi-Synthelabo Inc.; plus generics), valproate sodium (Depacon, Abbott; plus generics), and valproic acid (Depakene, Abbott; plus generics) are other common drug-related causes. Take a thorough medication history that includes these agents as well as progesterone.

There is no drug specifically indicated to treat hirsutism approved for marketing by the Food and Drug Administration. One agent, eflornithine (Vaniqa, SkinMedica Inc.) is approved only for reduction of unwanted facial hair. "It decreases the rate of hair growth and amount of shaving a woman has to do," Dr. Olsen said. "It's a decrease in the rate of hair growth only" and not the amount of hair, so patient education and realistic expectations are important.

Disclosures: Dr. Olsen said she is a consultant for Merck & Co., an investigator for Eisai Pharmaceuticals, and she receives research support from both companies.

NAPLES, Fla. - Dermatologists know best how to prevent and to correct facial filler complications, compared with medi-spa aestheticians and other employees, Dr. Oscar Hevia said.

“Our ability to identify, treat, and correct our complications [is what will set us apart]. It’s all about experience,” Dr. Hevia said at the meeting.

Some complications are more specific to particular filler types or products, whereas others can occur regardless of which agent is chosen to enhance the forehead, infraorbital area, or the naso­labial folds, for example. Appropriate expertise goes beyond recognition of early complications in the first 2 weeks, to include late complications (that arise within 1 year), and delayed complications thereafter.

“Forehead contouring is not an area we normally think about with fillers. [However,] you can get a nice correction in someone who might have brow ptosis if you used a toxin,” said Dr. Hevia, who is in private practice in Miami and on the faculty in the department of dermatology and cutaneous surgery at the University of Miami Leonard M. Miller School of Medicine.

“Looking at the eyes, the superior temporal rim is important too. Take away any bony landmarks around the eyes,” he said.

More commonly, patients will ask dermatologists to improve their infraorbital hollows. Injection of fillers to replace lost volume below the eyes is part of his restorative approach to the face, Dr. Hevia said. “Much of the early aging in patients is really around the eyes. You are taking someone from worn or tired ... to looking their best.” Calcium hydroxyapatite (Radiesse, BioForm Medical Inc.) and polydimethylsiloxane (Silikon 1000, Alcon Laboratories) are options for filling the infraorbital area.

Along with these techniques comes the potential for complications. For example, it is easy to overcorrect with calcium hydroxyapatite injections under the eyes, Dr. Hevia said. “You really should use a half-inch 30-G needle, small volumes, a little at a time, and you will do fine.” A yellowish discoloration after this product is injected into thin skin, such as under the eyes, is another specific potential complication, he added.

Bruising, tenderness, erythema, and vascular compromise are nonspecific complications, or events not associated with a specific filler product or type.

“Bruising is part of life. You are going to see it, especially when you inject around the eye,” Dr. Hevia said. If postprocedure bruising is superficial, you can treat it with lasers, he added.

Caution with infraorbital injections also is warranted when a patient has visible malar mounds. Injection of any filler into the compartmentalized fat pads under the eyes might exacerbate them, Dr. Hevia said. Infraorbital edema is another nonspecific complication in this ana­tomic area.

Hematoma and vascular compromises are other adverse events not necessarily associated with any particular facial filler product.

There also are more specific sequelae. For example, incorrect injection of polydimethylsiloxane can cause delayed overcorrection of nasolabial folds, rhytids, or acne scars. Dr. Hevia cited one patient, for example, with facial acne scars who developed protruding bumps on her skin. Placement of this filler too superficially is usually to blame.

Granuloma is another complication associated with some filler products more than others, Dr. Hevia said. “What we see in Miami is a ‘biopolymer’ granulomatous response.” Some patients get biopolymer injections at a medi-spa and then present to Dr. Hevia with delayed overcorrections, such as around their upper lip.

Late- or delayed-onset granuloma also can occur with poly-l-lactic acid injections, Dr. Hevia said. “In some patients, this can arise more than a year later.”

Disclosures: Dr. Hevia said he had no relevant financial disclosures.

NAPLES, Fla. - Dermatologists know best how to prevent and to correct facial filler complications, compared with medi-spa aestheticians and other employees, Dr. Oscar Hevia said.

“Our ability to identify, treat, and correct our complications [is what will set us apart]. It’s all about experience,” Dr. Hevia said at the meeting.

Some complications are more specific to particular filler types or products, whereas others can occur regardless of which agent is chosen to enhance the forehead, infraorbital area, or the naso­labial folds, for example. Appropriate expertise goes beyond recognition of early complications in the first 2 weeks, to include late complications (that arise within 1 year), and delayed complications thereafter.

“Forehead contouring is not an area we normally think about with fillers. [However,] you can get a nice correction in someone who might have brow ptosis if you used a toxin,” said Dr. Hevia, who is in private practice in Miami and on the faculty in the department of dermatology and cutaneous surgery at the University of Miami Leonard M. Miller School of Medicine.

“Looking at the eyes, the superior temporal rim is important too. Take away any bony landmarks around the eyes,” he said.

More commonly, patients will ask dermatologists to improve their infraorbital hollows. Injection of fillers to replace lost volume below the eyes is part of his restorative approach to the face, Dr. Hevia said. “Much of the early aging in patients is really around the eyes. You are taking someone from worn or tired ... to looking their best.” Calcium hydroxyapatite (Radiesse, BioForm Medical Inc.) and polydimethylsiloxane (Silikon 1000, Alcon Laboratories) are options for filling the infraorbital area.

Along with these techniques comes the potential for complications. For example, it is easy to overcorrect with calcium hydroxyapatite injections under the eyes, Dr. Hevia said. “You really should use a half-inch 30-G needle, small volumes, a little at a time, and you will do fine.” A yellowish discoloration after this product is injected into thin skin, such as under the eyes, is another specific potential complication, he added.

Bruising, tenderness, erythema, and vascular compromise are nonspecific complications, or events not associated with a specific filler product or type.

“Bruising is part of life. You are going to see it, especially when you inject around the eye,” Dr. Hevia said. If postprocedure bruising is superficial, you can treat it with lasers, he added.

Caution with infraorbital injections also is warranted when a patient has visible malar mounds. Injection of any filler into the compartmentalized fat pads under the eyes might exacerbate them, Dr. Hevia said. Infraorbital edema is another nonspecific complication in this ana­tomic area.

Hematoma and vascular compromises are other adverse events not necessarily associated with any particular facial filler product.

There also are more specific sequelae. For example, incorrect injection of polydimethylsiloxane can cause delayed overcorrection of nasolabial folds, rhytids, or acne scars. Dr. Hevia cited one patient, for example, with facial acne scars who developed protruding bumps on her skin. Placement of this filler too superficially is usually to blame.

Granuloma is another complication associated with some filler products more than others, Dr. Hevia said. “What we see in Miami is a ‘biopolymer’ granulomatous response.” Some patients get biopolymer injections at a medi-spa and then present to Dr. Hevia with delayed overcorrections, such as around their upper lip.

Late- or delayed-onset granuloma also can occur with poly-l-lactic acid injections, Dr. Hevia said. “In some patients, this can arise more than a year later.”

Disclosures: Dr. Hevia said he had no relevant financial disclosures.

NAPLES, Fla. - Dermatologists know best how to prevent and to correct facial filler complications, compared with medi-spa aestheticians and other employees, Dr. Oscar Hevia said.

“Our ability to identify, treat, and correct our complications [is what will set us apart]. It’s all about experience,” Dr. Hevia said at the meeting.

Some complications are more specific to particular filler types or products, whereas others can occur regardless of which agent is chosen to enhance the forehead, infraorbital area, or the naso­labial folds, for example. Appropriate expertise goes beyond recognition of early complications in the first 2 weeks, to include late complications (that arise within 1 year), and delayed complications thereafter.

“Forehead contouring is not an area we normally think about with fillers. [However,] you can get a nice correction in someone who might have brow ptosis if you used a toxin,” said Dr. Hevia, who is in private practice in Miami and on the faculty in the department of dermatology and cutaneous surgery at the University of Miami Leonard M. Miller School of Medicine.

“Looking at the eyes, the superior temporal rim is important too. Take away any bony landmarks around the eyes,” he said.

More commonly, patients will ask dermatologists to improve their infraorbital hollows. Injection of fillers to replace lost volume below the eyes is part of his restorative approach to the face, Dr. Hevia said. “Much of the early aging in patients is really around the eyes. You are taking someone from worn or tired ... to looking their best.” Calcium hydroxyapatite (Radiesse, BioForm Medical Inc.) and polydimethylsiloxane (Silikon 1000, Alcon Laboratories) are options for filling the infraorbital area.

Along with these techniques comes the potential for complications. For example, it is easy to overcorrect with calcium hydroxyapatite injections under the eyes, Dr. Hevia said. “You really should use a half-inch 30-G needle, small volumes, a little at a time, and you will do fine.” A yellowish discoloration after this product is injected into thin skin, such as under the eyes, is another specific potential complication, he added.

Bruising, tenderness, erythema, and vascular compromise are nonspecific complications, or events not associated with a specific filler product or type.

“Bruising is part of life. You are going to see it, especially when you inject around the eye,” Dr. Hevia said. If postprocedure bruising is superficial, you can treat it with lasers, he added.

Caution with infraorbital injections also is warranted when a patient has visible malar mounds. Injection of any filler into the compartmentalized fat pads under the eyes might exacerbate them, Dr. Hevia said. Infraorbital edema is another nonspecific complication in this ana­tomic area.

Hematoma and vascular compromises are other adverse events not necessarily associated with any particular facial filler product.

There also are more specific sequelae. For example, incorrect injection of polydimethylsiloxane can cause delayed overcorrection of nasolabial folds, rhytids, or acne scars. Dr. Hevia cited one patient, for example, with facial acne scars who developed protruding bumps on her skin. Placement of this filler too superficially is usually to blame.

Granuloma is another complication associated with some filler products more than others, Dr. Hevia said. “What we see in Miami is a ‘biopolymer’ granulomatous response.” Some patients get biopolymer injections at a medi-spa and then present to Dr. Hevia with delayed overcorrections, such as around their upper lip.

Late- or delayed-onset granuloma also can occur with poly-l-lactic acid injections, Dr. Hevia said. “In some patients, this can arise more than a year later.”

Disclosures: Dr. Hevia said he had no relevant financial disclosures.