Heidi Splete

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

WASHINGTON — High intelligence may be protective against brain injury-associated cognitive dysfunction, judging from follow-up data on veterans injured during the war in Vietnam, Jordan Grafman, Ph.D., said at a meeting sponsored by the Institute of Medicine.

Dr. Grafman, chief of the cognitive neurosciences section of the National Institute of Neurological Disorders and Stroke, presented new data from 35 years of following Vietnam War veterans with traumatic brain injury (TBI). The study is the most recent phase in the ongoing Vietnam Head Injury Study, a long-term follow-up of veterans who suffered head injuries in combat. The cohort included 199 men with TBI and 55 controls; their average age at most recent follow up was 59 years.

Participants completed a variation of a U.S. Army classification test used to assess mental ability. The test was similar to an intelligence test that the soldiers took when they first enlisted. Overall, 4.5% of the participants scored less than 24 on the Mini-Mental State Examination, but those who scored lower also had below-average baseline intelligence scores.

The controls showed a cognitive decline with age, and the soldiers with penetrating head injuries showed a slightly greater decline, even when investigators controlled for a host of variables.

“But if you look at subgroups, those with the lowest preinjury intelligence scores had the most cognitive decline from preinjury to follow-up, and the difference was statistically significant, compared with controls,” Dr. Grafman said. He also noted that soldiers with head injuries who show exacerbated cognitive decline as they age may be mistakenly diagnosed with dementia, when in fact their increased cognitive decline results from a combination of aging and the size of their lesions.

Based in part on these findings, Dr. Grafman does not believe that TBI is always a precursor to Alzheimer's disease. But the long-term findings suggest that the location of the injury contributes to late-life cognitive decline and other symptoms.

“Lesions of the caudate nucleus of the brain significantly and consistently predicted late-life cognitive decline, and may indicate the importance of certain neurotransmitters in maintaining functions as we age,” Dr. Grafman said.

By contrast, the location of a TBI can be protective, too. Posttraumatic stress is clearly part of the experience of war, especially if someone experiences combat, Dr. Grafman said. But none the men with injuries to the amygdala showed signs of posttraumatic stress disorder, whereas 18% of those men with ventromedial prefrontal cortex lesions and more than 40% of patients with lesions elsewhere in the brain had developed PTSD over time since their injuries.

Dr. Grafman emphasized the importance of longitudinal studies for brain injury patients in general, and for veterans in particular, because baseline data are often available. “Preinjury intelligence is by far the best predictor of outcome, no matter what other variables you throw in,” Dr. Grafman said, based on the 35-year data and data from the same group of veterans at 5 and 15 years' follow-up. Data gathered on the cohort at 10 years showed individuals who scored higher on baseline intelligence tests were more likely to be working years later, and they were more able to handle daily activities, compared with those who had lower baseline intelligence scores.

Veterans are an outstanding patient group, and a systematic plan is needed to keep them from being lost in the medical system, Dr. Grafman noted, adding, “There needs to be a well-run centralized database for the registry of head-injured soldiers with a small number of manageable variables.”

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially on the face or a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

Not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, of the University of California, San Francisco. These patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients under 21 years evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures. “We collected information on body surface area of involvement. And we had a dermatology perspective rather than a rheumatology perspective,” Dr. Gilliam said.

“The presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation,” she said. Add the 19 patients who had what they called a “bruise,” and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another finding was that patients whose scleroderma involved 5% or more of total body surface area were significantly more likely to have extracutaneous symptoms—arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of total body surface. This held in separate analyses of 89 patients whose charts were reviewed retrospectively and 38 patients studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. “That sticks out like a sore thumb,” said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

“When we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement,” she said.

Apart from the relationship with body surface area, Dr. Gilliam showed neurologic problems were more common in patients with facial linear scleroderma versus other forms of localized scleroderma (33% vs. 8%). Her data showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone isn't enough to assess localized scleroderma, Dr. Gilliam said. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Dr. Gilliam did not find a significant link between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873-81). She found positive antinuclear antibody levels were slightly, but not significantly, more prevalent in patients with linear scleroderma and with generalized morphea.

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

MINNEAPOLIS — Metabolic changes and comorbid conditions are just a few of the challenges involved in treating insomnia in older adults.

“The predictability of your giving drug X to patient A and knowing what is going to happen goes way down. That's the bottom line,” said Dr. Daniel Buysse, a professor of psychiatry and the director of the Clinical Neuroscience Research Center at the University of Pittsburgh.

The physiologic changes that occur with aging affect how the body absorbs medication, Dr. Buysse said at the annual meeting of the Associated Professional Sleep Societies.

“As we get older, our lean body mass decreases and our adipose tissue increases,” he noted. Because the drugs used to treat insomnia are lipid soluble, older adults who have a greater proportion of adipose tissue will store the drug longer before processing it through the body, Dr. Buysse explained. Consequently, older patients may have more residual sleepiness the next day after taking a sleep medication the previous night, and their dosages may need adjustment.

Hypnotics have shown effectiveness in treating insomnia in adults, but be aware that the measured blood concentrations of drugs are much more variable in an older population, Dr. Buysse said. In addition, some data have shown that hypnotics are associated with cognitive and psycho- motor problems in older patients.

Antidepressants such as trazodone may be helpful for some patients; but be aware of the risks of dizziness, which could lead to falls, and the risk of oversedation because of older adults' slower metabolisms.

Choosing insomnia medications for older adults is tricky, said Dr. Alon Avidan, a neurologist at the University of California, Los Angeles. Drugs have their risks, but untreated insomnia can be just as risky, because it has been linked to an increased risk of falls in older adults. Elderly people who wake up at night are likely to get out of bed, which means that they are at greater risk for falls than older adults who are able to sleep longer.

In fact, hypnotics may be protective in preventing falls in older adults with insomnia, Dr. Avidan said, based on data from his study of more than 34,000 nursing home residents with an average age of 84 years (J. Am. Geriatr. Soc. 2005;53:955–62).

The patients with untreated insomnia were 30% more likely to fall, compared with those who were treated with hypnotics. But treating insomnia had no measurable effect on the patients' risk for hip fractures, Dr. Avidan noted.

Dr. Buysse shared his top clinical considerations when choosing drug therapies for elderly patients with insomnia.

First, keep expectations realistic, he advised. “The fact that older adults have comorbidities may limit how well we can do with our treatments,” he noted. Comorbid health conditions may affect how older adults feel during the day regardless of whether they have slept well.

Second, remind patients that insomnia medication is not a general anesthesia. “Some older adults look at sleep as a behavioral alternative when they run out of things to do,” Dr. Buysse said. “Some patients take a pill at 8 p.m. and they think they will be out for the night.”

In addition, remember that no evidence-based treatment guidelines exist to direct treatment of insomnia in older adults.

“We have not the least idea how to match a particular treatment to a patient, and we don't really know what constitutes a clinically significant response,” Dr. Buysse said.

Findings from a recent meta-analysis suggest that many of the drugs currently available for treating insomnia—including the nonbenzodiazepine hypnotics zolpidem and zaleplon, some benzodiazepines, and the antidepressant drug trazodone—have not shown consistent effectiveness in improving sleep in older adults (Ann. Clin. Psychiatry 2006;18:49–56).

Dr. Buysse recommended starting with a benzodiazepine receptor agonist, and then switching to a sedating antidepressant if the benzodiazepine doesn't help.

“When people still don't improve, you could start moving to other methods such as behavioral therapy,” he said.

More research is needed to understand how to combine drug therapy with behavior therapy to treat insomnia in older adults, he added.

Keep expectations realistic. 'The fact that older adults have comorbidities may limit how well we can do with our treatments.' DR. BUYSSE

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Intermittent treatment with tacrolimus ointment kept atopic dermatitis under control with no need for corticosteroids in patients aged 2–15 years whose conditions had stabilized, according to a presentation at the annual meeting of the Society for Pediatric Dermatology.

Concerns persist about the long-term effects of corticosteroid use by children and teens, so safe and effective alternatives are needed for the long-term management of atopic dermatitis (AD). The black box warning attached to tacrolimus (Protopic) says that continuous use should be avoided, so Dr. Amy S. Paller of Northwestern University, Chicago, and her colleagues designed a plan that involved applying tacrolimus ointment to the affected skin three times weekly for 40 weeks.

The goal was to prevent flares in patients whose AD had stabilized. The randomized trial of the protocol's safety and effectiveness was sponsored by Astellas Pharma US Inc.

A total of 206 patients were randomized, but 54 discontinued the study. The most common reason for discontinuation was loss to follow-up (15 patients). Ten children dropped out because of uncontrolled rebound exacerbation of their AD, and five dropped out because of an adverse event.

Overall, those who received tacrolimus ointment had significantly fewer relapse days (47) than those who received a control ointment containing alclometasone (76 days). The tacrolimus patients remained stable for significantly more days before their first relapses (116 days vs. 31 days).

Only 6% of the children in the tacrolimus group relapsed for up to 3 days during the study period. In the control group, 19% of the children relapsed for up to 6 days. The most common adverse events reported by tacrolimus patients were burning and itching at the application site, which reflects results from previous safety studies.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

CHICAGO — Many genetically based periodic fever syndromes have skin signs that may help identify the syndromes on the rare occasions when they occur, Dr. Kathryn M. Edwards said at the annual meeting of the Society for Pediatric Dermatology.

Although these syndromes, called familial periodic fever syndromes, are rare, knowing something about them will “allow you to think more about how we control fever and inflammatory processes in children,” noted Dr. Edwards, professor of pediatrics at Vanderbilt University, Nashville, Tenn.

“Periodic fever is a very specific diagnosis,” said Dr. Edwards, an expert vaccinologist who has conducted research for the National Institutes of Health. Periodic fevers are fevers that recur at intervals lasting from a few days to a few weeks separated by totally symptom-free intervals.

A periodic fever syndrome is a form of autoinflammatory disorder. “Generally periodic fevers that have been present for more than 2 years are never associated with infection or malignancy,” she explained.

In one study, 29 children with periodic fevers tended to be younger at the onset of the fever (often less than 1 year of age), had a longer duration of symptoms before they were referred for further evaluation, and had higher maximum fever temperatures, compared with 11 children with daily fevers (J. Pediatr. 1996;129:419–23).

About a quarter of the periodic fever patients had a nonspecific rash, but so did the children with daily fevers. Comorbid rash and fever isn't enough to diagnose a familial periodic fever syndrome. But pharyngitis and oral ulcers or adenopathy were seen much more often in patients with periodic fever during their intervals of fever than in those with daily fevers.

The familial syndromes are characterized by identified genetic defects that inhibit the body's ability to control inflammation, and genetic testing is needed to confirm a diagnosis of these syndromes.

There are distinct patterns of ancestry for familial periodic fever syndromes and the genes have been circulating for generations, said Dr. Edwards. “The familial febrile syndromes are not easy to diagnose, and if you have a patient who you suspect has one of these syndromes, please contact the NIH for genotyping,” she said.

Following are the familial periodic fever syndromes she described:

▸ Familial Mediterranean Fever (FMF). FMF is linked to a recessive gene known as MEFV. Many patients experience secondary amyloidosis, in which a protein buildup in various organs and tissues can impede their functions. FMF is common in Jewish families of Spanish, Portuguese, or Middle Eastern descent, but it is rare in Jewish families of European descent, Dr. Edwards noted.

Clinical features include serositis and scrotal swelling, and the periodic attacks of fever often begin in childhood. The most common dermatologic manifestation is a distinctive erysipeloid rash on the lower extremities that occurs in about 15% of children with this syndrome. Studies have shown that about half of these patients also report arthritis in one ankle, knee, or hip. The fever attacks in FMF patients occur at regular intervals, and they usually respond to treatment within 12–72 hours. Colchicine treatment has been shown to be effective in preventing the fever episodes (and the subsequent rash), although not in treating the acute attacks of fever once they occur.

“If you treat people with FMF regularly with colchicine they don't get attacks of fever and they don't get amyloidosis, so it is important that FMF is diagnosed,” Dr. Edwards said.

▸ Hyperimmunoglobulinemia D Syndrome (HIDS). HIDS has an early onset (the median age of onset is 6 months), and recurrent attacks of fever persist throughout the patient's life. Febrile attacks usually last for 3–7 days at irregular intervals ranging from 4 to 8 weeks. Clinical features include cervical adenitis, vomiting, and diarrhea. A patient with HIDS may present to a dermatologist with a maculopapular rash, with petechiae and purpura that appear during a febrile attack. Generalized lymphadenopathy and rash are very common in these patients.

Distinctive laboratory features include an elevated IgD (greater than 14.3 mg/dL), but this elevation is not present in all HIDS patients. The gene for HIDS has been mapped to chromosome 12 and at least 8 different mutations or deletions have been seen, but the syndrome is most likely to occur in people with Dutch or French ancestry, Dr. Edwards said.

▸ Tumor Necrosis Factor-Receptor Associated Periodic Syndrome (TRAPS). Children with TRAPS may have a lifelong history of febrile episodes that last 2–3 weeks at a time, but the febrile episodes only occur 2–3 times per year.

Conjunctivitis and raised red lesions distinguish TRAPS from other familial periodic fever syndromes. One study of 25 TRAPS patients showed that 21 (84%) had erythematous patches, including both wavy and circular lesions (N. Engl. J. Med. 2001;345:1748–57). Other clinical features of TRAPS include myalgia, arthralgia, and abdominal pain.

Skin manifestations are much more common with TRAPS than with the other familial periodic fever syndromes. “Almost all of these children will have skin lesions that may persist even when the fever is gone,” Dr. Edwards noted.

When a febrile episode occurs, TNF receptors are suppressed, which creates an uncontrolled inflammatory response. Consequently, TNF inhibitors can be used to treat these patients, Dr. Edwards said.

▸ Muckle-Wells Syndrome/Familial Cold Urticaria. These two syndromes are both associated with mutations of the CIAS1 gene family. Mutations in these genes lead to autoinflammatory syndromes in which large numbers of cytokines are generated, which means that amyloidosis is very frequent in these individuals.

Patients with Muckle-Wells syndrome (MWS) generally present with urticaria and progressive sensorineural loss and deafness. Because MWS is a disease of dominant genes, the parent may show signs of hearing problems, which should prompt clinicians to include MWS in the differential diagnosis of recurrent urticaria and fever.

By contrast, patients with familial cold urticaria will present not only with urticaria and wheals, but with complaints of painful joints, chills, and fever. Febrile episodes in patients with familial cold urticaria generally occur several hours after exposure to cold. Both syndromes are associated with German, English, French, and North American ancestry.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.

MINNEAPOLIS – Women with no history of sleep disorders often report sleep problems–especially difficulty falling asleep–as they undergo menopause. Their complaints were validated by a sleep study of more than 700 women presented at the annual meeting of the Associated Professional Sleep Societies.

“These data provide, for the first time, objective findings to support this common sleep complaint in postmenopausal women,” asserted Edward O. Bixler, Ph.D., who is vice chair of the sleep research division at Pennsylvania State University in Hershey.

To confirm the association between menopause and poor sleep and to seek a possible mechanism for this connection, Dr. Bixler and his colleagues conducted single-night polysomnographies on 715 women with a mean age of 49 years. Of these, 400 women were premenopausal, 120 were postmenopausal and using hormone therapy (HT), and 195 were postmenopausal but not using HT.

Women sleep as well as or better than men until they reach menopause, but sleep needs change with age, Dr. Bixler noted.

With this fact in mind, the researchers used a group of 609 men who were at least 45 years old (with an average age of 49 years) as controls for the study. The average body mass index for both genders was 26.9 kg/m

The results of the single-night sleep test showed that the postmenopausal women who were not on hormone therapy took an average of 15 minutes longer to fall asleep, compared with women who were on HT, and an average of 10 minutes longer to fall asleep compared with the men. These differences were statistically significant.

The average time it took for the male controls to fall asleep was not significantly different from that of premenopausal women (a difference of 1.6 minutes) or of postmenopausal women who were taking hormone therapy (a difference of 5.6 minutes).

“What was unexpected was that we didn't find an increase in daytime sleepiness,” Dr. Bixler noted. He proposed that the lack of daytime sleepiness might be a result of the reduced need for sleep that is a natural part of aging. “As you age, you are less likely to be sleepy during the day even though you are sleeping less at night,” he said.

When the researchers looked at slow wave sleep, which is associated with the brain's ability to recharge, think, and remember, they found no differences between premenopausal women and male controls.

Postmenopausal women who didn't use HT, however, were twice as likely to have slow wave sleep as were male controls, and postmenopausal women who used HT were four times as likely to have slow wave sleep as were male controls. Therefore, postmenopausal women who used HT were twice as likely to have slow wave sleep as were women who didn't use HT.

The data suggest that sleep latency is a valid symptom among menopausal women without a history of sleep disorders, especially among those who are not using HT. Based on these findings, menopausal women may be at increased risk for developing chronic insomnia that may require treatment, Dr. Bixler added.

“We would speculate that [menopausal changes] may be triggers for the onset of primary insomnia in vulnerable women,” he said.

WASHINGTON – Long-term data from a registry of civilians with traumatic brain injury may yield information that is relevant to the care of injured veterans returning from Iraq and Afghanistan, said Jean A. Langlois, Sc.D., at a meeting on traumatic brain injuries sponsored by the Institute of Medicine.

During her presentation, Dr. Langlois noted that there are relatively few long-term cohort studies of blast-induced TBI and the possible combined effects of these injuries and posttraumatic stress disorder (PTSD). The data she presented showed that civilian survivors of TBI often develop costly disabilities. More aggressive treatment might make a difference. “I think we will be seeing several directions for interventions, including electrical brain stimulation,” Dr. Langlois said.

Approximately 124,000 civilians in the United States are hospitalized each year with TBI, and about 40% of these patients will experience long-term disabilities, said Dr. Langlois, an epidemiologist at the Centers for Disease Control and Prevention.

Findings from previous studies have shown that even uninjured military personnel who return from combat are at increased risk of psychosocial and psychiatric problems, including PTSD, major depression, suicide, impaired social function, and limited ability to work, she noted.

She reviewed data from four population-based studies using the South Carolina Traumatic Brain Injury Follow-up Registry that included patients with TBI who required hospitalization. The TBI was severe in 45% of patients, moderate in 15%, and mild in 40%. Patients were aged 15 years or older, 60% were male, and 75% were white.

The first of the four studies evaluated psychosocial health in 2,118 patients 1 year after TBI. Based on the scores from a validated social function scale, 29% of the TBI patients reported poor psychosocial health 1 year after their injuries, which is more than one standard deviation below the population norms, Dr. Langlois said.

“We found almost double the rate of psychosocial health problems [compared with the rate in] the general population, but only 36% reported receiving any mental health care after TBI,” she said (Arch. Phys. Med. Rehabil. 2006;87:953–61).

Factors associated with poor psychosocial health 1 year after TBI included female gender, preinjury or postinjury psychiatric conditions, inadequate social support, physical limitations for activities of daily living, and preinjury drug or alcohol abuse problems.

Surprisingly, adults with TBI were less likely to report heavy alcohol consumption 1 year after injury, based on data from 1,606 patients.

The researchers used the CDC's Behavioral Risk Factor Surveillance summary questions to assess drinking habits. They found that 94% of the patients reported drinking the same amount or less alcohol 1 year after TBI than they did before TBI. And 50% of those who called themselves heavy drinkers reported drinking less. Heavy drinking was defined as an average of five or more drinks per occasion, or 22 or more drinking days within a month (J. Int. Neuropsychol. Soc. 2005;11:322–30).

But compared with the general population, the TBI population was more likely to binge drink (defined as five or more drinks on one occasion), and almost twice as likely to have five or more occasions to binge drink. Factors associated with heavy drinking were male gender, younger age, lack of support, diagnosis of depression since TBI, and self-reported fair to moderate (vs. excellent) mental health.

Also, research has shown that substance abuse problems may surface in later years after TBI, rather than immediately following the injury, said Dr. Langlois, citing a review of evidence that, on average, the quantities of alcohol consumed by TBI patients increased over time after their injuries (Arch. Phys. Med. Rehabil. 1995;76:302–9).

Clinical implications of heavy drinking include decreased recovery from TBI, increased impulsivity, exacerbation of cognitive problems, increased risk for seizures, and increased risk for additional brain injuries, Dr. Langlois added.

A third study focused on employment 1 year after TBI. These findings may have unique implications for returning military personnel who may not be able to redeploy and who will need to rejoin the civilian work force, Dr. Langlois said. The employment study included patients from the South Carolina database, plus data on people with TBI who were not in the South Carolina registry, for a total of 3,444 patients (2,487 men and 957 women).

At 1 year after TBI, a majority (41%) of the patients had stopped working, 36% had kept the same hours, 13% were working fewer hours, and 10% were working more hours, Dr. Langlois said.

Factors associated with not working included a longer hospital stay, nonwhite race, and having Medicaid or workers' compensation.

When the patients were divided by gender, men aged 20–24 years were the most likely to be working after 1 year, possibly because they tended to be the primary wage earners, whereas older men may have better disability or health benefits, Dr. Langlois noted. By contrast, women aged 18–24 years were most likely to be not working 1 year after TBI, possibly because they tend to be caring for children at home or because they may have complications if their injuries resulted from domestic violence, Dr. Langlois said.

Dr. Langlois concluded with a study of mortality within 1 year of TBI based on the South Carolina population data from 3,679 persons hospitalized with TBI (J. Head Trauma Rehab. 2005;20:257–69). Overall, the risk for all-cause mortality was seven times higher, compared with the U.S. death rate, and 80% of these deaths were reported as being related to the TBI, Dr. Langlois said.

Patients with severe TBI were significantly more likely to die within 15 months, compared with mild or moderate cases. Other factors associated with mortality from TBI included older age (75 years or older) and more comorbid conditions (three or more). The most common comorbidities were heart disease (48%), hypertension (29%), and fluid/electrolyte imbalance (21%).

WASHINGTON – Long-term data from a registry of civilians with traumatic brain injury may yield information that is relevant to the care of injured veterans returning from Iraq and Afghanistan, said Jean A. Langlois, Sc.D., at a meeting on traumatic brain injuries sponsored by the Institute of Medicine.

During her presentation, Dr. Langlois noted that there are relatively few long-term cohort studies of blast-induced TBI and the possible combined effects of these injuries and posttraumatic stress disorder (PTSD). The data she presented showed that civilian survivors of TBI often develop costly disabilities. More aggressive treatment might make a difference. “I think we will be seeing several directions for interventions, including electrical brain stimulation,” Dr. Langlois said.

Approximately 124,000 civilians in the United States are hospitalized each year with TBI, and about 40% of these patients will experience long-term disabilities, said Dr. Langlois, an epidemiologist at the Centers for Disease Control and Prevention.

Findings from previous studies have shown that even uninjured military personnel who return from combat are at increased risk of psychosocial and psychiatric problems, including PTSD, major depression, suicide, impaired social function, and limited ability to work, she noted.

She reviewed data from four population-based studies using the South Carolina Traumatic Brain Injury Follow-up Registry that included patients with TBI who required hospitalization. The TBI was severe in 45% of patients, moderate in 15%, and mild in 40%. Patients were aged 15 years or older, 60% were male, and 75% were white.

The first of the four studies evaluated psychosocial health in 2,118 patients 1 year after TBI. Based on the scores from a validated social function scale, 29% of the TBI patients reported poor psychosocial health 1 year after their injuries, which is more than one standard deviation below the population norms, Dr. Langlois said.

“We found almost double the rate of psychosocial health problems [compared with the rate in] the general population, but only 36% reported receiving any mental health care after TBI,” she said (Arch. Phys. Med. Rehabil. 2006;87:953–61).

Factors associated with poor psychosocial health 1 year after TBI included female gender, preinjury or postinjury psychiatric conditions, inadequate social support, physical limitations for activities of daily living, and preinjury drug or alcohol abuse problems.

Surprisingly, adults with TBI were less likely to report heavy alcohol consumption 1 year after injury, based on data from 1,606 patients.

The researchers used the CDC's Behavioral Risk Factor Surveillance summary questions to assess drinking habits. They found that 94% of the patients reported drinking the same amount or less alcohol 1 year after TBI than they did before TBI. And 50% of those who called themselves heavy drinkers reported drinking less. Heavy drinking was defined as an average of five or more drinks per occasion, or 22 or more drinking days within a month (J. Int. Neuropsychol. Soc. 2005;11:322–30).

But compared with the general population, the TBI population was more likely to binge drink (defined as five or more drinks on one occasion), and almost twice as likely to have five or more occasions to binge drink. Factors associated with heavy drinking were male gender, younger age, lack of support, diagnosis of depression since TBI, and self-reported fair to moderate (vs. excellent) mental health.

Also, research has shown that substance abuse problems may surface in later years after TBI, rather than immediately following the injury, said Dr. Langlois, citing a review of evidence that, on average, the quantities of alcohol consumed by TBI patients increased over time after their injuries (Arch. Phys. Med. Rehabil. 1995;76:302–9).

Clinical implications of heavy drinking include decreased recovery from TBI, increased impulsivity, exacerbation of cognitive problems, increased risk for seizures, and increased risk for additional brain injuries, Dr. Langlois added.

A third study focused on employment 1 year after TBI. These findings may have unique implications for returning military personnel who may not be able to redeploy and who will need to rejoin the civilian work force, Dr. Langlois said. The employment study included patients from the South Carolina database, plus data on people with TBI who were not in the South Carolina registry, for a total of 3,444 patients (2,487 men and 957 women).

At 1 year after TBI, a majority (41%) of the patients had stopped working, 36% had kept the same hours, 13% were working fewer hours, and 10% were working more hours, Dr. Langlois said.

Factors associated with not working included a longer hospital stay, nonwhite race, and having Medicaid or workers' compensation.

When the patients were divided by gender, men aged 20–24 years were the most likely to be working after 1 year, possibly because they tended to be the primary wage earners, whereas older men may have better disability or health benefits, Dr. Langlois noted. By contrast, women aged 18–24 years were most likely to be not working 1 year after TBI, possibly because they tend to be caring for children at home or because they may have complications if their injuries resulted from domestic violence, Dr. Langlois said.

Dr. Langlois concluded with a study of mortality within 1 year of TBI based on the South Carolina population data from 3,679 persons hospitalized with TBI (J. Head Trauma Rehab. 2005;20:257–69). Overall, the risk for all-cause mortality was seven times higher, compared with the U.S. death rate, and 80% of these deaths were reported as being related to the TBI, Dr. Langlois said.

Patients with severe TBI were significantly more likely to die within 15 months, compared with mild or moderate cases. Other factors associated with mortality from TBI included older age (75 years or older) and more comorbid conditions (three or more). The most common comorbidities were heart disease (48%), hypertension (29%), and fluid/electrolyte imbalance (21%).

WASHINGTON – Long-term data from a registry of civilians with traumatic brain injury may yield information that is relevant to the care of injured veterans returning from Iraq and Afghanistan, said Jean A. Langlois, Sc.D., at a meeting on traumatic brain injuries sponsored by the Institute of Medicine.

During her presentation, Dr. Langlois noted that there are relatively few long-term cohort studies of blast-induced TBI and the possible combined effects of these injuries and posttraumatic stress disorder (PTSD). The data she presented showed that civilian survivors of TBI often develop costly disabilities. More aggressive treatment might make a difference. “I think we will be seeing several directions for interventions, including electrical brain stimulation,” Dr. Langlois said.

Approximately 124,000 civilians in the United States are hospitalized each year with TBI, and about 40% of these patients will experience long-term disabilities, said Dr. Langlois, an epidemiologist at the Centers for Disease Control and Prevention.

Findings from previous studies have shown that even uninjured military personnel who return from combat are at increased risk of psychosocial and psychiatric problems, including PTSD, major depression, suicide, impaired social function, and limited ability to work, she noted.

She reviewed data from four population-based studies using the South Carolina Traumatic Brain Injury Follow-up Registry that included patients with TBI who required hospitalization. The TBI was severe in 45% of patients, moderate in 15%, and mild in 40%. Patients were aged 15 years or older, 60% were male, and 75% were white.

The first of the four studies evaluated psychosocial health in 2,118 patients 1 year after TBI. Based on the scores from a validated social function scale, 29% of the TBI patients reported poor psychosocial health 1 year after their injuries, which is more than one standard deviation below the population norms, Dr. Langlois said.

“We found almost double the rate of psychosocial health problems [compared with the rate in] the general population, but only 36% reported receiving any mental health care after TBI,” she said (Arch. Phys. Med. Rehabil. 2006;87:953–61).

Factors associated with poor psychosocial health 1 year after TBI included female gender, preinjury or postinjury psychiatric conditions, inadequate social support, physical limitations for activities of daily living, and preinjury drug or alcohol abuse problems.

Surprisingly, adults with TBI were less likely to report heavy alcohol consumption 1 year after injury, based on data from 1,606 patients.

The researchers used the CDC's Behavioral Risk Factor Surveillance summary questions to assess drinking habits. They found that 94% of the patients reported drinking the same amount or less alcohol 1 year after TBI than they did before TBI. And 50% of those who called themselves heavy drinkers reported drinking less. Heavy drinking was defined as an average of five or more drinks per occasion, or 22 or more drinking days within a month (J. Int. Neuropsychol. Soc. 2005;11:322–30).

But compared with the general population, the TBI population was more likely to binge drink (defined as five or more drinks on one occasion), and almost twice as likely to have five or more occasions to binge drink. Factors associated with heavy drinking were male gender, younger age, lack of support, diagnosis of depression since TBI, and self-reported fair to moderate (vs. excellent) mental health.

Also, research has shown that substance abuse problems may surface in later years after TBI, rather than immediately following the injury, said Dr. Langlois, citing a review of evidence that, on average, the quantities of alcohol consumed by TBI patients increased over time after their injuries (Arch. Phys. Med. Rehabil. 1995;76:302–9).

Clinical implications of heavy drinking include decreased recovery from TBI, increased impulsivity, exacerbation of cognitive problems, increased risk for seizures, and increased risk for additional brain injuries, Dr. Langlois added.

A third study focused on employment 1 year after TBI. These findings may have unique implications for returning military personnel who may not be able to redeploy and who will need to rejoin the civilian work force, Dr. Langlois said. The employment study included patients from the South Carolina database, plus data on people with TBI who were not in the South Carolina registry, for a total of 3,444 patients (2,487 men and 957 women).

At 1 year after TBI, a majority (41%) of the patients had stopped working, 36% had kept the same hours, 13% were working fewer hours, and 10% were working more hours, Dr. Langlois said.

Factors associated with not working included a longer hospital stay, nonwhite race, and having Medicaid or workers' compensation.

When the patients were divided by gender, men aged 20–24 years were the most likely to be working after 1 year, possibly because they tended to be the primary wage earners, whereas older men may have better disability or health benefits, Dr. Langlois noted. By contrast, women aged 18–24 years were most likely to be not working 1 year after TBI, possibly because they tend to be caring for children at home or because they may have complications if their injuries resulted from domestic violence, Dr. Langlois said.

Dr. Langlois concluded with a study of mortality within 1 year of TBI based on the South Carolina population data from 3,679 persons hospitalized with TBI (J. Head Trauma Rehab. 2005;20:257–69). Overall, the risk for all-cause mortality was seven times higher, compared with the U.S. death rate, and 80% of these deaths were reported as being related to the TBI, Dr. Langlois said.

Patients with severe TBI were significantly more likely to die within 15 months, compared with mild or moderate cases. Other factors associated with mortality from TBI included older age (75 years or older) and more comorbid conditions (three or more). The most common comorbidities were heart disease (48%), hypertension (29%), and fluid/electrolyte imbalance (21%).

Adolescents who first drank alcohol before 13 years of age were significantly more likely to exhibit suicidal behavior than their peers who didn't drink alcohol, based on results from the 2005 Youth Risk Behavior Survey of 13,639 U.S. students in grades 9–12.

About a quarter (25%) of the survey respondents reported drinking alcohol when they were younger than 13 years. Adolescents who reported preteen alcohol use were more than twice as likely to attempt suicide and nearly twice as likely to report suicidal thoughts, compared with nondrinking peers, reported Monica H. Swahn, Ph.D., and Robert M. Bossarte, Ph.D., of the Centers for Disease Control and Prevention, Atlanta.

Alcohol use is a known risk factor for suicidal behavior in adolescents, but the researchers sought specific links between suicidal behavior and preteen alcohol use after controlling for multiple factors such as age, gender, race, history of sadness, history of physical abuse, and history of carrying a weapon, they said (J. Adolesc. Health 2007;41:175–81).

Further analysis showed that, among girls, preteen alcohol use initiation was significantly associated with increased risk of suicidal thoughts–but not suicide attempts–relative to first consuming alcohol after age 13. Among boys, preteen alcohol use initiation was significantly associated with an increased risk of both suicidal thoughts and suicide attempts, compared with nondrinking teens, but not when compared with boys who first consumed alcohol at age 13 years or older.

The findings support results from previous studies that link alcohol use to suicidal behavior in teens, but the data differ from previous studies by not supporting gender differences in the increased risk of suicidal behavior in preteen drinkers. Future research should address risk factors, protective factors, and motivation for alcohol use in younger adolescents to develop prevention and intervention plans, Dr. Swahn and Dr. Bossarte said.

Adolescents who first drank alcohol before 13 years of age were significantly more likely to exhibit suicidal behavior than their peers who didn't drink alcohol, based on results from the 2005 Youth Risk Behavior Survey of 13,639 U.S. students in grades 9–12.

About a quarter (25%) of the survey respondents reported drinking alcohol when they were younger than 13 years. Adolescents who reported preteen alcohol use were more than twice as likely to attempt suicide and nearly twice as likely to report suicidal thoughts, compared with nondrinking peers, reported Monica H. Swahn, Ph.D., and Robert M. Bossarte, Ph.D., of the Centers for Disease Control and Prevention, Atlanta.

Alcohol use is a known risk factor for suicidal behavior in adolescents, but the researchers sought specific links between suicidal behavior and preteen alcohol use after controlling for multiple factors such as age, gender, race, history of sadness, history of physical abuse, and history of carrying a weapon, they said (J. Adolesc. Health 2007;41:175–81).

Further analysis showed that, among girls, preteen alcohol use initiation was significantly associated with increased risk of suicidal thoughts–but not suicide attempts–relative to first consuming alcohol after age 13. Among boys, preteen alcohol use initiation was significantly associated with an increased risk of both suicidal thoughts and suicide attempts, compared with nondrinking teens, but not when compared with boys who first consumed alcohol at age 13 years or older.

The findings support results from previous studies that link alcohol use to suicidal behavior in teens, but the data differ from previous studies by not supporting gender differences in the increased risk of suicidal behavior in preteen drinkers. Future research should address risk factors, protective factors, and motivation for alcohol use in younger adolescents to develop prevention and intervention plans, Dr. Swahn and Dr. Bossarte said.

Adolescents who first drank alcohol before 13 years of age were significantly more likely to exhibit suicidal behavior than their peers who didn't drink alcohol, based on results from the 2005 Youth Risk Behavior Survey of 13,639 U.S. students in grades 9–12.

About a quarter (25%) of the survey respondents reported drinking alcohol when they were younger than 13 years. Adolescents who reported preteen alcohol use were more than twice as likely to attempt suicide and nearly twice as likely to report suicidal thoughts, compared with nondrinking peers, reported Monica H. Swahn, Ph.D., and Robert M. Bossarte, Ph.D., of the Centers for Disease Control and Prevention, Atlanta.

Alcohol use is a known risk factor for suicidal behavior in adolescents, but the researchers sought specific links between suicidal behavior and preteen alcohol use after controlling for multiple factors such as age, gender, race, history of sadness, history of physical abuse, and history of carrying a weapon, they said (J. Adolesc. Health 2007;41:175–81).

Further analysis showed that, among girls, preteen alcohol use initiation was significantly associated with increased risk of suicidal thoughts–but not suicide attempts–relative to first consuming alcohol after age 13. Among boys, preteen alcohol use initiation was significantly associated with an increased risk of both suicidal thoughts and suicide attempts, compared with nondrinking teens, but not when compared with boys who first consumed alcohol at age 13 years or older.

The findings support results from previous studies that link alcohol use to suicidal behavior in teens, but the data differ from previous studies by not supporting gender differences in the increased risk of suicidal behavior in preteen drinkers. Future research should address risk factors, protective factors, and motivation for alcohol use in younger adolescents to develop prevention and intervention plans, Dr. Swahn and Dr. Bossarte said.

WASHINGTON — Adding a smoking cessation component to electronic medical record systems improves the likelihood that hospitalized individuals with a history of smoking will receive cessation counseling, according to study results presented at a conference sponsored by the National Patient Safety Foundation.

Because hospitalization forces patients to temporarily abstain from smoking, identifying smokers when they are hospitalized with other illnesses may help them quit, Dr. Vikram Verma wrote in a poster.

Dr. Verma and colleagues at Kings County Hospital Center in Brooklyn, N.Y., reviewed 420 patient charts during the 6-month period prior to adding a smoking cessation component to the electronic medical record (EMR). The researchers identified 62 smokers (15%). Of these, 24 (39%) received nicotine replacement therapy and 29 patients refused NRT. For the other nine, the smoking cessation issue remained unaddressed.

The EMR included a mandatory “tobacco evaluation” field to guarantee that the smoking status was assessed in all patients. In addition, an electronic reminder to prescribe transdermal NRT appears in the records of all patients who smoke, and any patients who are “positive” in the smoking history field are automatically referred to a smoking cessation counselor.

During the 6-month period after adding the smoking cessation field to the EMR, the researchers identified 85 smokers when they reviewed another 420 patient charts. The issue of smoking cessation was addressed in 100% of those patients, although 65 (76%) refused NRT.

“The program facilitated our efforts in providing smoking cessation counseling,” the researchers said. Also, adding smoking status to the EMR may help with long-term studies of patients' smoking status.

WASHINGTON — Adding a smoking cessation component to electronic medical record systems improves the likelihood that hospitalized individuals with a history of smoking will receive cessation counseling, according to study results presented at a conference sponsored by the National Patient Safety Foundation.

Because hospitalization forces patients to temporarily abstain from smoking, identifying smokers when they are hospitalized with other illnesses may help them quit, Dr. Vikram Verma wrote in a poster.

Dr. Verma and colleagues at Kings County Hospital Center in Brooklyn, N.Y., reviewed 420 patient charts during the 6-month period prior to adding a smoking cessation component to the electronic medical record (EMR). The researchers identified 62 smokers (15%). Of these, 24 (39%) received nicotine replacement therapy and 29 patients refused NRT. For the other nine, the smoking cessation issue remained unaddressed.

The EMR included a mandatory “tobacco evaluation” field to guarantee that the smoking status was assessed in all patients. In addition, an electronic reminder to prescribe transdermal NRT appears in the records of all patients who smoke, and any patients who are “positive” in the smoking history field are automatically referred to a smoking cessation counselor.

During the 6-month period after adding the smoking cessation field to the EMR, the researchers identified 85 smokers when they reviewed another 420 patient charts. The issue of smoking cessation was addressed in 100% of those patients, although 65 (76%) refused NRT.

“The program facilitated our efforts in providing smoking cessation counseling,” the researchers said. Also, adding smoking status to the EMR may help with long-term studies of patients' smoking status.

WASHINGTON — Adding a smoking cessation component to electronic medical record systems improves the likelihood that hospitalized individuals with a history of smoking will receive cessation counseling, according to study results presented at a conference sponsored by the National Patient Safety Foundation.

Because hospitalization forces patients to temporarily abstain from smoking, identifying smokers when they are hospitalized with other illnesses may help them quit, Dr. Vikram Verma wrote in a poster.

Dr. Verma and colleagues at Kings County Hospital Center in Brooklyn, N.Y., reviewed 420 patient charts during the 6-month period prior to adding a smoking cessation component to the electronic medical record (EMR). The researchers identified 62 smokers (15%). Of these, 24 (39%) received nicotine replacement therapy and 29 patients refused NRT. For the other nine, the smoking cessation issue remained unaddressed.

The EMR included a mandatory “tobacco evaluation” field to guarantee that the smoking status was assessed in all patients. In addition, an electronic reminder to prescribe transdermal NRT appears in the records of all patients who smoke, and any patients who are “positive” in the smoking history field are automatically referred to a smoking cessation counselor.

During the 6-month period after adding the smoking cessation field to the EMR, the researchers identified 85 smokers when they reviewed another 420 patient charts. The issue of smoking cessation was addressed in 100% of those patients, although 65 (76%) refused NRT.

“The program facilitated our efforts in providing smoking cessation counseling,” the researchers said. Also, adding smoking status to the EMR may help with long-term studies of patients' smoking status.

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially if it is on the face or on a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

However, not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, a dermatologist at the University of California, San Francisco. Instead, these patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients younger than 21 years who were evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures.

"Something unique in our study is that we collected information on body surface area of involvement," Dr. Gilliam said. "And we had a dermatology perspective rather than a rheumatology perspective.

"One of the interesting things that came out of our data was that the presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation," she said. Add the 19 patients who had what they called a "bruise," and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another key finding was that patients whose scleroderma involved 5% or more of their total body surface area were significantly more likely to have extracutaneous symptoms—including arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of their total body surface area. The significance was true in separate analyses of the 89 patients whose charts were reviewed retrospectively and the 38 patients who were studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. "That sticks out like a sore thumb," said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

This finding "makes complete sense to me, because when we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement," she said.

Apart from the relationship with body surface area, Dr. Gilliam was able to prove that neurologic problems were more common in patients with facial linear scleroderma compared with those who had other forms of localized scleroderma (33% vs. 8%). Her data also showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone is not enough to assess localized scleroderma, Dr. Gilliam emphasized. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Lastly, Dr. Gilliam did not find a significant association between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873–81).

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially if it is on the face or on a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

However, not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, a dermatologist at the University of California, San Francisco. Instead, these patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients younger than 21 years who were evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures.

"Something unique in our study is that we collected information on body surface area of involvement," Dr. Gilliam said. "And we had a dermatology perspective rather than a rheumatology perspective.

"One of the interesting things that came out of our data was that the presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation," she said. Add the 19 patients who had what they called a "bruise," and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another key finding was that patients whose scleroderma involved 5% or more of their total body surface area were significantly more likely to have extracutaneous symptoms—including arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of their total body surface area. The significance was true in separate analyses of the 89 patients whose charts were reviewed retrospectively and the 38 patients who were studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. "That sticks out like a sore thumb," said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

This finding "makes complete sense to me, because when we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement," she said.

Apart from the relationship with body surface area, Dr. Gilliam was able to prove that neurologic problems were more common in patients with facial linear scleroderma compared with those who had other forms of localized scleroderma (33% vs. 8%). Her data also showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone is not enough to assess localized scleroderma, Dr. Gilliam emphasized. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Lastly, Dr. Gilliam did not find a significant association between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873–81).

CHICAGO — When facing a child with localized scleroderma, be wary if the scleroderma is linear, especially if it is on the face or on a limb where it crosses a joint, Dr. Amy Gilliam said at the annual meeting of the Society for Pediatric Dermatology.

However, not all young people initially present with the skin hardening and atrophy that characterizes scleroderma, explained Dr. Gilliam, a dermatologist at the University of California, San Francisco. Instead, these patients are often misdiagnosed with vitiligo for months or years before the correct diagnosis of juvenile localized scleroderma is made.

To better characterize localized scleroderma in children, Dr. Gilliam and her colleagues reviewed data from 127 patients younger than 21 years who were evaluated at UCSF. Dr. Gilliam's research was supported in part by a grant from the Society for Pediatric Dermatology and the Dermatology Foundation, but she had no other financial disclosures.

"Something unique in our study is that we collected information on body surface area of involvement," Dr. Gilliam said. "And we had a dermatology perspective rather than a rheumatology perspective.

"One of the interesting things that came out of our data was that the presenting sign in about 50% of the patients was some type of dyspigmentation, either hyper-, hypo- or depigmentation," she said. Add the 19 patients who had what they called a "bruise," and dyspigmentation was a presenting symptom in nearly two-thirds of the cases.

Another key finding was that patients whose scleroderma involved 5% or more of their total body surface area were significantly more likely to have extracutaneous symptoms—including arthralgias and orthopedic, pulmonary, and gastrointestinal problems—than were patients whose scleroderma involved less than 5% of their total body surface area. The significance was true in separate analyses of the 89 patients whose charts were reviewed retrospectively and the 38 patients who were studied prospectively and followed.

But neurologic problems were the notable exception in the patient population. "That sticks out like a sore thumb," said Dr. Gilliam. Localized scleroderma on less than 5% of the body surface area was significantly associated with neurologic problems, and neurologic problems were significantly more common in patients with facial linear scleroderma.

This finding "makes complete sense to me, because when we are talking about neurologic problems in the setting of localized scleroderma, we are usually talking about the face, which has at most 6% of the surface area, so these patients with neurologic problems are likely to have lower total body surface area involvement," she said.

Apart from the relationship with body surface area, Dr. Gilliam was able to prove that neurologic problems were more common in patients with facial linear scleroderma compared with those who had other forms of localized scleroderma (33% vs. 8%). Her data also showed that orthopedic problems were significantly more common in patients with nonfacial linear scleroderma, compared with those who had other forms of localized scleroderma (22% vs. 2%).

But body surface area alone is not enough to assess localized scleroderma, Dr. Gilliam emphasized. The patients to worry about are those with segmental or linear presentations and those with the characteristic pinkish-purple macules that indicate generalized morphea.

It's important to think about location in cases of localized scleroderma, Dr. Gilliam added. In her study, gastrointestinal problems were significantly more common in patients with generalized morphea and in patients who had scleroderma on the trunk, compared with those who had scleroderma in other locations (21% vs. 5%). But location isn't everything: Pulmonary problems were significantly more common among patients with generalized morphea, but the presence or absence of localized scleroderma on the trunk was not significant.

Lastly, Dr. Gilliam did not find a significant association between positive levels of antinuclear antibodies and extracutaneous conditions, although she cited a separate study of 750 patients that did show a significant association (Arthritis Rheum. 2005;52:2873–81).