Heidi Splete

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

Melatonin may help children with attention-deficit/hyperactivity disorder get more sleep, but behavior benefits are negligible, said Kristiaan B. Van der Heijden, Ph.D., of the Epilepsy Center Kempenhaeghe, Heeze, the Netherlands, and colleagues.

Surprisingly, melatonin had no significant effect on behavior, cognitive improvement, or quality of life. “We expected such improvements because sleep problems and sleep deprivation in children were associated with behavioral disturbances,” they said (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:233–41).

The findings did confirm that melatonin improves sleep. In the randomized, double-blind study, 105 children aged 6–12 years took daily doses of 3 mg or 6 mg of melatonin (depending on their weight) or a placebo for 4 weeks.

The children who received melatonin fell asleep an average of 27 minutes earlier than at baseline, and those who took placebo fell asleep an average of 11 minutes later.

In addition, total sleep time increased by an average of 20 minutes in the melatonin group, and decreased by an average of 14 minutes in the placebo group.

Five patients in the melatonin group reported adverse events, including headache, hyperactivity, dizziness, and abdominal pain, but none of these patients discontinued the medication or withdrew from the study, and none required treatment for the adverse reactions.

Melatonin should be prescribed only for persistent and severe cases of insomnia, given the lack of additional benefits and the lack of systematic studies of the long-term effects of consistent melatonin use, the investigators wrote.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

LAS VEGAS — Magnetic resonance imaging can help physicians evaluate an anterior cruciate ligament tear and plan surgery to repair an ACL injury, said Dr. Kathryn Stevens at a symposium on emergency medicine sponsored by Stanford University.

MRI identifies additional bony or cartilage injuries—notably, injuries to the posterolateral corner of the knee—that increase the risk of knee instability when coupled with an ACL tear, said Dr. Stevens, a diagnostic radiologist at Stanford (Calif.) University.

“If you don't recognize posterolateral corner structures when you go in to do an ACL repair, the ACL graft is more likely to fail,” she said.

Always look at the posterolateral corner structures on an MRI of the knee prior to surgery, she emphasized. Prompt imaging is helpful because surgery within 3 weeks of injury yields the most effective results, she noted.

The ACL consists of two bundles of dense connective tissue, the anteromedial and the posterolateral bundles. ACL tears typically occur when a person slows down or changes direction quickly and are most common in younger athletes whose sports involve quick starts, stops, and pivots, such as basketball, soccer, and skiing, said Dr. Stevens.

Although MRI is not essential for diagnosing an ACL tear, some physicians opt to order images for confirmation. Diagnostic criteria for an ACL tear that are visible on an MRI include an empty notch on a coronal image, an edematous mass, and a wavy contour to the knee. Indirect signs of an ACL tear that are visible on an MRI include the “kissing contusions” where the edges of the leg bones barely touch. Kissing contusions identify cartilage involvement in ACL tears, especially if the image shows that the posterior horn of the lateral meniscus is no longer covered by the knee.

The posterolateral corner structures consist of three layers. Attachment points for the patellar retinaculum, the iliotibial band, and the biceps tendon are all found in the first layer; the lateral collateral ligament in the second layer; and the arcuate and fabellofibular ligaments in the third layer.

Common posterolateral corner injuries include an arcuate fracture (a tearing away of the fibula at the point where the arcuate ligament attaches to the knee) and a Segond fracture (a tearing away of the meniscotibial part of the lateral capsular ligament). More than 90% of Segond fractures are associated with ACL tears, Dr. Stevens said.

Posterolateral corner injuries are relatively rare but can compromise the success of ACL surgery. Such injuries are receiving more attention, in part because they can be better identified with current imaging techniques, she added.

After surgery, MRI can be used to evaluate graft alignment and to identify instability or infection. When ACL surgery doesn't go well, MRI can identify graft impingement or graft rupture. Graft impingement will show up as increased signal intensity within two-thirds of the graft area; graft rupture will show up as increased signal intensity in the general area where the graft should be, Dr. Stevens said.

Coronal CT and coronal T2 FS images show an avulsion fracture of Gerdy's tubercle (white arrow, left) and an avulsion of the iliotibial band (black arrows, right). Photos courtesy Dr. Kathryn Stevens

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The new guidelines represent a change from previous recommendations, which advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE), an infection of the heart's valves or inner lining.

Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (doi:10.1161/circulationaha.106.183095).

In addition, no prospective randomized placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE, although research in this area is limited by the range of dental procedures and overall low incidence of IE. And daily activities such as toothbrushing and flossing cause transient bacteremia, and far more frequently than dental procedures.

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

The cardiac patients who should continue to receive antibiotics prior to dental procedures because of their increased risk for severe complications from IE are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients who have developed abnormal cardiac valves.

In addition, patients with cardiac disease who meet the following criteria should continue to receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the heart vessels' inner surfaces.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

The patients who meet the criteria for increased IE risk should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Disease Society as well as approved by the American Dental Association.

The preexisting guidelines for antibiotics use to prevent IE were last revised in 1997, and they called for 2 g of amoxicillin to be given orally 1 hour before a procedure.

But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, and antibiotic use only to prevent IE is no longer recommended for any cardiac patients prior to gastrointestinal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The previous recommendations advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE). Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (Circulation 2007 May 8 [Epub doi:10.1161/circulationaha.106.183095]).

In addition, no prospective randomized, placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE. And daily activities such as toothbrushing and flossing cause transient bacteremia. (See story below.)

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

Patients who should receive antibiotics prior to dental procedures are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients with abnormal cardiac valves.

In addition, patients who meet the following criteria should receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the inner surfaces of the heart vessels.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

Such patients should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America, Pediatric Infectious Disease Society, and American Dental Association.

The previous guidelines, last revised in 1997, called for 2 g of amoxicillin to be given orally 1 hour before a procedure. But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The previous recommendations advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE). Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (Circulation 2007 May 8 [Epub doi:10.1161/circulationaha.106.183095]).

In addition, no prospective randomized, placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE. And daily activities such as toothbrushing and flossing cause transient bacteremia. (See story below.)

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

Patients who should receive antibiotics prior to dental procedures are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients with abnormal cardiac valves.

In addition, patients who meet the following criteria should receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the inner surfaces of the heart vessels.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

Such patients should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America, Pediatric Infectious Disease Society, and American Dental Association.

The previous guidelines, last revised in 1997, called for 2 g of amoxicillin to be given orally 1 hour before a procedure. But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

Most patients with heart conditions don't need to take antibiotics to reduce the risk of infection prior to a dental procedure, according to revised American Heart Association guidelines.

The previous recommendations advised that patients with any heart abnormality, from mild valve prolapse to severe birth defects, should take amoxicillin prior to a dental procedure to reduce the risk of developing infective endocarditis (IE). Many types of fungi and bacteria can cause the infection, and dental procedures had been seen as opening the door for these organisms to attack vulnerable patients.

But the guidelines writing group, led by Dr. Walter Wilson of the Mayo Clinic in Rochester, Minn., reviewed the latest research and found no significant evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk for infections (Circulation 2007 May 8 [Epub doi:10.1161/circulationaha.106.183095]).

In addition, no prospective randomized, placebo-controlled studies have shown that antibiotic use prior to a dental procedure prevents IE. And daily activities such as toothbrushing and flossing cause transient bacteremia. (See story below.)

In fact, severe adverse events resulting from IE are associated with only a small subgroup of cardiac conditions, the writing group noted, and these patients should continue to receive antibiotics prior to dental procedures.

Patients who should receive antibiotics prior to dental procedures are those with prosthetic cardiac valves or previous episodes of infective endocarditis, and heart transplant patients with abnormal cardiac valves.

In addition, patients who meet the following criteria should receive antibiotics prior to dental procedures:

▸ Patients with repaired congenital heart disease (CHD) who have remaining defects at or near the site of a patch or prosthetic that inhibit the healing of the inner surfaces of the heart vessels.

▸ Patients with unrepaired cyanotic CHD, including those with palliative shunts or conduits.

▸ Patients with repaired CHD with no remaining defects who are within 6 months of the procedure (because the inner vessel surfaces are still healing).

Such patients should receive antibiotics prior to any dental procedure that involves work on the gums, the apex of the tooth, or perforation of oral mucosa. The guidelines apply to children as well as adults and have been endorsed by the Infectious Diseases Society of America, Pediatric Infectious Disease Society, and American Dental Association.

The previous guidelines, last revised in 1997, called for 2 g of amoxicillin to be given orally 1 hour before a procedure. But amoxicillin use carries risks of its own, including fostering the development of amoxicillin-resistant organisms, and data have not supported any reduced risk of IE as a result of prophylactic antibiotic use prior to dental procedures.

The new guidelines emphasize that antibiotic use should be based on the odds of a heart patient having a severe adverse reaction if he or she developed IE, rather than lumping all heart patients together as being at increased risk for IE.

“In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics,” Dr. Wilson said in a statement. Dr. Wilson had no financial disclosures related to his work on the guidelines.

Similarly, only cardiac patients who meet the above criteria need to receive antibiotics prior to respiratory tract, skin, or musculoskeletal procedures, according to the new guidelines.

Physicians might need to reassure patients with heart conditions other than the high-risk conditions specified in the guidelines that their risk for developing IE is low, and remind them that the ability of antibiotics to reduce the risk of IE is equally low, the writing group noted.

WASHINGTON – Many fibromyalgia patients could benefit from the care and expertise provided by psychiatrists, Dr. Lesley M. Arnold said at the annual meeting of the American Academy of Clinical Psychiatrists.

Psychiatrists are in a position to evaluate fibromyalgia patients for psychiatric comorbidities and consider prescribing antidepressants as part of a treatment plan, said Dr. Arnold, associate professor of psychiatry at the University of Cincinnati.

Tricyclics have been shown to reduce chronic pain independent of any effects on the patient's mood, which suggests a common neurochemical channel for persistent pain and psychiatric conditions that remains unexplored, she said.

Consequently, fibromyalgia patients might benefit from a multidisciplinary approach, said Dr. Arnold, who has received grants and research support from several pharmaceutical companies, including Eli Lilly, Pfizer, and Cypress Bioscience. She also has served as a consultant for these and other pharmaceutical companies.

The American College of Rheumatology criteria for fibromyalgia include chronic widespread pain of more than 3 months' duration and pain in at least 11 of 18 pressure point areas of the body. Patients must report pain with about 4 kg of pressure (enough to blanch your thumb when you press on the area).

But the muscular criteria are only part of the disorder. Patients with fibromyalgia may have hyperalgesia throughout the body rather than at specific points, and patients who do not report pressure on at least 11 of the 18 tender points will often report other symptoms of fibromyalgia, including debilitating fatigue, Dr. Arnold said.

“Fatigue really knocks people out, and that impairs their function more than the pain,” she commented. Fibromyalgia patients also report difficulty falling asleep, difficulty staying asleep, and unrefreshing sleep.

Patients with fibromyalgia report depression and anxiety symptoms, too. The fibromyalgia literature suggests that about one-third of patients with a fibromyalgia diagnosis have a comorbid psychiatric condition, which contributes to the rationale for treating fibromyalgia patients with antidepressants, Dr. Arnold said.

To further assess the relationship between psychiatric comorbidity and fibromyalgia, Dr. Arnold and colleagues conducted a family study. They recruited 78 patients with fibromyalgia and 533 of their relatives, and compared the prevalence of mood disorders between this population and 40 patients with rheumatoid arthritis and 272 of their relatives (Arthritis Rheum. 2004;50;944–52).

“Mood disorders were much more common in the relatives of the fibromyalgia patients than the RA patients,” she said. Overall, 32% of relatives of fibromyalgia patients had any mood disorder versus 19% of relatives of rheumatoid arthritis patients. On further analysis, the odds ratio for bipolar disorder was much higher in patients with fibromyalgia, compared with those who didn't have fibromyalgia, she added.

When prescribing antidepressants off label to fibromyalgia patients with comorbid mood disorders, be sure to titrate the medication to a high enough dose for a long enough time to allow a response, Dr. Arnold said.

“There is a tendency to use low doses when treating chronic pain, but I encourage people to use the full standard dose,” she said. Also consider combining a tricyclic antidepressant with a selective serotonin reuptake inhibitor, but be aware of drug interactions. “Sometimes you need to do two treatments–one for mood and one for pain,” she added.

Dr. Arnold and her colleagues conducted two randomized trials to assess the effectiveness of duloxetine (Cymbalta) on reducing pain in fibromyalgia patients with and without major depressive disorder. Overall, duloxetine was associated with significantly less pain than a placebo, whether or not the patients had major depressive disorder (Arthritis Rheum. 2004;50:2974–84).

Similarly, pregabalin and gabapentin are approved by the Food and Drug Administration for treating some types of neuropathic pain and neuralgia, and they are being studied as treatments for anxiety disorders and fibromyalgia.

WASHINGTON – Many fibromyalgia patients could benefit from the care and expertise provided by psychiatrists, Dr. Lesley M. Arnold said at the annual meeting of the American Academy of Clinical Psychiatrists.

Psychiatrists are in a position to evaluate fibromyalgia patients for psychiatric comorbidities and consider prescribing antidepressants as part of a treatment plan, said Dr. Arnold, associate professor of psychiatry at the University of Cincinnati.

Tricyclics have been shown to reduce chronic pain independent of any effects on the patient's mood, which suggests a common neurochemical channel for persistent pain and psychiatric conditions that remains unexplored, she said.

Consequently, fibromyalgia patients might benefit from a multidisciplinary approach, said Dr. Arnold, who has received grants and research support from several pharmaceutical companies, including Eli Lilly, Pfizer, and Cypress Bioscience. She also has served as a consultant for these and other pharmaceutical companies.

The American College of Rheumatology criteria for fibromyalgia include chronic widespread pain of more than 3 months' duration and pain in at least 11 of 18 pressure point areas of the body. Patients must report pain with about 4 kg of pressure (enough to blanch your thumb when you press on the area).

But the muscular criteria are only part of the disorder. Patients with fibromyalgia may have hyperalgesia throughout the body rather than at specific points, and patients who do not report pressure on at least 11 of the 18 tender points will often report other symptoms of fibromyalgia, including debilitating fatigue, Dr. Arnold said.

“Fatigue really knocks people out, and that impairs their function more than the pain,” she commented. Fibromyalgia patients also report difficulty falling asleep, difficulty staying asleep, and unrefreshing sleep.

Patients with fibromyalgia report depression and anxiety symptoms, too. The fibromyalgia literature suggests that about one-third of patients with a fibromyalgia diagnosis have a comorbid psychiatric condition, which contributes to the rationale for treating fibromyalgia patients with antidepressants, Dr. Arnold said.

To further assess the relationship between psychiatric comorbidity and fibromyalgia, Dr. Arnold and colleagues conducted a family study. They recruited 78 patients with fibromyalgia and 533 of their relatives, and compared the prevalence of mood disorders between this population and 40 patients with rheumatoid arthritis and 272 of their relatives (Arthritis Rheum. 2004;50;944–52).

“Mood disorders were much more common in the relatives of the fibromyalgia patients than the RA patients,” she said. Overall, 32% of relatives of fibromyalgia patients had any mood disorder versus 19% of relatives of rheumatoid arthritis patients. On further analysis, the odds ratio for bipolar disorder was much higher in patients with fibromyalgia, compared with those who didn't have fibromyalgia, she added.

When prescribing antidepressants off label to fibromyalgia patients with comorbid mood disorders, be sure to titrate the medication to a high enough dose for a long enough time to allow a response, Dr. Arnold said.

“There is a tendency to use low doses when treating chronic pain, but I encourage people to use the full standard dose,” she said. Also consider combining a tricyclic antidepressant with a selective serotonin reuptake inhibitor, but be aware of drug interactions. “Sometimes you need to do two treatments–one for mood and one for pain,” she added.

Dr. Arnold and her colleagues conducted two randomized trials to assess the effectiveness of duloxetine (Cymbalta) on reducing pain in fibromyalgia patients with and without major depressive disorder. Overall, duloxetine was associated with significantly less pain than a placebo, whether or not the patients had major depressive disorder (Arthritis Rheum. 2004;50:2974–84).

Similarly, pregabalin and gabapentin are approved by the Food and Drug Administration for treating some types of neuropathic pain and neuralgia, and they are being studied as treatments for anxiety disorders and fibromyalgia.

WASHINGTON – Many fibromyalgia patients could benefit from the care and expertise provided by psychiatrists, Dr. Lesley M. Arnold said at the annual meeting of the American Academy of Clinical Psychiatrists.

Psychiatrists are in a position to evaluate fibromyalgia patients for psychiatric comorbidities and consider prescribing antidepressants as part of a treatment plan, said Dr. Arnold, associate professor of psychiatry at the University of Cincinnati.

Tricyclics have been shown to reduce chronic pain independent of any effects on the patient's mood, which suggests a common neurochemical channel for persistent pain and psychiatric conditions that remains unexplored, she said.

Consequently, fibromyalgia patients might benefit from a multidisciplinary approach, said Dr. Arnold, who has received grants and research support from several pharmaceutical companies, including Eli Lilly, Pfizer, and Cypress Bioscience. She also has served as a consultant for these and other pharmaceutical companies.

The American College of Rheumatology criteria for fibromyalgia include chronic widespread pain of more than 3 months' duration and pain in at least 11 of 18 pressure point areas of the body. Patients must report pain with about 4 kg of pressure (enough to blanch your thumb when you press on the area).

But the muscular criteria are only part of the disorder. Patients with fibromyalgia may have hyperalgesia throughout the body rather than at specific points, and patients who do not report pressure on at least 11 of the 18 tender points will often report other symptoms of fibromyalgia, including debilitating fatigue, Dr. Arnold said.

“Fatigue really knocks people out, and that impairs their function more than the pain,” she commented. Fibromyalgia patients also report difficulty falling asleep, difficulty staying asleep, and unrefreshing sleep.

Patients with fibromyalgia report depression and anxiety symptoms, too. The fibromyalgia literature suggests that about one-third of patients with a fibromyalgia diagnosis have a comorbid psychiatric condition, which contributes to the rationale for treating fibromyalgia patients with antidepressants, Dr. Arnold said.

To further assess the relationship between psychiatric comorbidity and fibromyalgia, Dr. Arnold and colleagues conducted a family study. They recruited 78 patients with fibromyalgia and 533 of their relatives, and compared the prevalence of mood disorders between this population and 40 patients with rheumatoid arthritis and 272 of their relatives (Arthritis Rheum. 2004;50;944–52).

“Mood disorders were much more common in the relatives of the fibromyalgia patients than the RA patients,” she said. Overall, 32% of relatives of fibromyalgia patients had any mood disorder versus 19% of relatives of rheumatoid arthritis patients. On further analysis, the odds ratio for bipolar disorder was much higher in patients with fibromyalgia, compared with those who didn't have fibromyalgia, she added.

When prescribing antidepressants off label to fibromyalgia patients with comorbid mood disorders, be sure to titrate the medication to a high enough dose for a long enough time to allow a response, Dr. Arnold said.

“There is a tendency to use low doses when treating chronic pain, but I encourage people to use the full standard dose,” she said. Also consider combining a tricyclic antidepressant with a selective serotonin reuptake inhibitor, but be aware of drug interactions. “Sometimes you need to do two treatments–one for mood and one for pain,” she added.

Dr. Arnold and her colleagues conducted two randomized trials to assess the effectiveness of duloxetine (Cymbalta) on reducing pain in fibromyalgia patients with and without major depressive disorder. Overall, duloxetine was associated with significantly less pain than a placebo, whether or not the patients had major depressive disorder (Arthritis Rheum. 2004;50:2974–84).

Similarly, pregabalin and gabapentin are approved by the Food and Drug Administration for treating some types of neuropathic pain and neuralgia, and they are being studied as treatments for anxiety disorders and fibromyalgia.

Children and adolescents with obsessive-compulsive disorder responded equally well to daily and weekly cognitive-behavioral therapy, Eric A. Storch, Ph.D., and his colleagues at the University of Florida, Gainesville, have reported.

To compare the effectiveness of intensive cognitive-behavioral therapy (CBT) with less frequent treatments in terms of reducing obsessive-compulsive symptoms, the researchers randomized 40 children aged 7–17 years who met the diagnostic criteria for obsessive-compulsive disorder to receive intensive (daily) sessions of CBT or weekly sessions, which are a current standard of care (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:469–78).

Dr. Storch and his colleagues assessed the children at baseline, after 14 sessions of daily or weekly therapy, and at a 3-month follow-up visit.

Symptoms were compared using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), which is a clinician-rated measure of obsessive-compulsive disorder severity.

Overall, children in both daily and weekly groups showed improvements on the CY-BOS scores, with posttreatment effect sizes of 2.62 and 1.73 respectively at the 3-month follow-up visit.

The findings suggest that additional care, perhaps in the form of weekly visits or phone calls, might be needed to sustain the benefits of intensive CBT over time. Both approaches eventually yield the same result, but a short program of intensive therapy might speed up a patient's progress, the researchers wrote.

Children and adolescents with obsessive-compulsive disorder responded equally well to daily and weekly cognitive-behavioral therapy, Eric A. Storch, Ph.D., and his colleagues at the University of Florida, Gainesville, have reported.

To compare the effectiveness of intensive cognitive-behavioral therapy (CBT) with less frequent treatments in terms of reducing obsessive-compulsive symptoms, the researchers randomized 40 children aged 7–17 years who met the diagnostic criteria for obsessive-compulsive disorder to receive intensive (daily) sessions of CBT or weekly sessions, which are a current standard of care (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:469–78).

Dr. Storch and his colleagues assessed the children at baseline, after 14 sessions of daily or weekly therapy, and at a 3-month follow-up visit.

Symptoms were compared using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), which is a clinician-rated measure of obsessive-compulsive disorder severity.

Overall, children in both daily and weekly groups showed improvements on the CY-BOS scores, with posttreatment effect sizes of 2.62 and 1.73 respectively at the 3-month follow-up visit.

The findings suggest that additional care, perhaps in the form of weekly visits or phone calls, might be needed to sustain the benefits of intensive CBT over time. Both approaches eventually yield the same result, but a short program of intensive therapy might speed up a patient's progress, the researchers wrote.

Children and adolescents with obsessive-compulsive disorder responded equally well to daily and weekly cognitive-behavioral therapy, Eric A. Storch, Ph.D., and his colleagues at the University of Florida, Gainesville, have reported.

To compare the effectiveness of intensive cognitive-behavioral therapy (CBT) with less frequent treatments in terms of reducing obsessive-compulsive symptoms, the researchers randomized 40 children aged 7–17 years who met the diagnostic criteria for obsessive-compulsive disorder to receive intensive (daily) sessions of CBT or weekly sessions, which are a current standard of care (J. Am. Acad. Child Adolesc. Psychiatry 2007;46:469–78).

Dr. Storch and his colleagues assessed the children at baseline, after 14 sessions of daily or weekly therapy, and at a 3-month follow-up visit.

Symptoms were compared using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), which is a clinician-rated measure of obsessive-compulsive disorder severity.

Overall, children in both daily and weekly groups showed improvements on the CY-BOS scores, with posttreatment effect sizes of 2.62 and 1.73 respectively at the 3-month follow-up visit.

The findings suggest that additional care, perhaps in the form of weekly visits or phone calls, might be needed to sustain the benefits of intensive CBT over time. Both approaches eventually yield the same result, but a short program of intensive therapy might speed up a patient's progress, the researchers wrote.

Treatment with antidepressants kept adolescent patients in the prepsychotic phase of schizophrenia from progressing to full psychosis or bipolar disorder more effectively than did treatment with antipsychotics, said Barbara A. Cornblatt, Ph.D., of Albert Einstein College of Medicine, New York, and her colleagues.

Because data from previous studies suggest that mental deterioration in schizophrenia patients might begin before the first psychotic episode, treating patients before they progress to full-blown psychosis might slow progression of illness and preserve psychosocial skills, the researchers said.

To assess the effectiveness of antidepressants on preventing progression to psychosis in adolescents, Dr. Cornblatt and her associates prescribed either antidepressants or second-generation antipsychotics to 48 adolescents who met criteria for prepsychotic schizophrenia (J. Clin. Psychiatry 2007;68:546–57). Dr. Cornblatt is a consultant for Eli Lilly & Co., and she has received financial support from Janssen L.P.

The antidepressant group included 20 patients who had never been treated with antipsychotics but had received antidepressants and other medications.

The second-generation antipsychotic group included 28 patients who had previously received antipsychotics alone or in combination with other medications.

The patients were assessed every 6 months during a follow-up period that lasted from 6 months to 5 years, and the symptoms were compared over time using the Scale of Prodromal Symptoms.

Overall, 12 of the 28 patients in the antipsychotic group but none of the patients in the antidepressant group converted to psychosis during the course of the study.

Of the 12 patients who converted, 7 progressed to syndromal schizophrenia, 4 progressed from an earlier prodromal phase to stronger schizophrenia symptoms, and 1 patient developed bipolar disorder with psychotic features.

The use of antipsychotics to treat prepsychotic adolescents is on the rise despite a lack of data, and more research is needed before such treatment becomes a standard practice, the researchers said. Their results suggest that medications other than antipsychotics might be beneficial for early intervention in patients at risk for developing full-blown schizophrenia.

Treatment with antidepressants kept adolescent patients in the prepsychotic phase of schizophrenia from progressing to full psychosis or bipolar disorder more effectively than did treatment with antipsychotics, said Barbara A. Cornblatt, Ph.D., of Albert Einstein College of Medicine, New York, and her colleagues.

Because data from previous studies suggest that mental deterioration in schizophrenia patients might begin before the first psychotic episode, treating patients before they progress to full-blown psychosis might slow progression of illness and preserve psychosocial skills, the researchers said.

To assess the effectiveness of antidepressants on preventing progression to psychosis in adolescents, Dr. Cornblatt and her associates prescribed either antidepressants or second-generation antipsychotics to 48 adolescents who met criteria for prepsychotic schizophrenia (J. Clin. Psychiatry 2007;68:546–57). Dr. Cornblatt is a consultant for Eli Lilly & Co., and she has received financial support from Janssen L.P.

The antidepressant group included 20 patients who had never been treated with antipsychotics but had received antidepressants and other medications.

The second-generation antipsychotic group included 28 patients who had previously received antipsychotics alone or in combination with other medications.

The patients were assessed every 6 months during a follow-up period that lasted from 6 months to 5 years, and the symptoms were compared over time using the Scale of Prodromal Symptoms.

Overall, 12 of the 28 patients in the antipsychotic group but none of the patients in the antidepressant group converted to psychosis during the course of the study.

Of the 12 patients who converted, 7 progressed to syndromal schizophrenia, 4 progressed from an earlier prodromal phase to stronger schizophrenia symptoms, and 1 patient developed bipolar disorder with psychotic features.

The use of antipsychotics to treat prepsychotic adolescents is on the rise despite a lack of data, and more research is needed before such treatment becomes a standard practice, the researchers said. Their results suggest that medications other than antipsychotics might be beneficial for early intervention in patients at risk for developing full-blown schizophrenia.

Treatment with antidepressants kept adolescent patients in the prepsychotic phase of schizophrenia from progressing to full psychosis or bipolar disorder more effectively than did treatment with antipsychotics, said Barbara A. Cornblatt, Ph.D., of Albert Einstein College of Medicine, New York, and her colleagues.

Because data from previous studies suggest that mental deterioration in schizophrenia patients might begin before the first psychotic episode, treating patients before they progress to full-blown psychosis might slow progression of illness and preserve psychosocial skills, the researchers said.

To assess the effectiveness of antidepressants on preventing progression to psychosis in adolescents, Dr. Cornblatt and her associates prescribed either antidepressants or second-generation antipsychotics to 48 adolescents who met criteria for prepsychotic schizophrenia (J. Clin. Psychiatry 2007;68:546–57). Dr. Cornblatt is a consultant for Eli Lilly & Co., and she has received financial support from Janssen L.P.

The antidepressant group included 20 patients who had never been treated with antipsychotics but had received antidepressants and other medications.

The second-generation antipsychotic group included 28 patients who had previously received antipsychotics alone or in combination with other medications.

The patients were assessed every 6 months during a follow-up period that lasted from 6 months to 5 years, and the symptoms were compared over time using the Scale of Prodromal Symptoms.

Overall, 12 of the 28 patients in the antipsychotic group but none of the patients in the antidepressant group converted to psychosis during the course of the study.

Of the 12 patients who converted, 7 progressed to syndromal schizophrenia, 4 progressed from an earlier prodromal phase to stronger schizophrenia symptoms, and 1 patient developed bipolar disorder with psychotic features.

The use of antipsychotics to treat prepsychotic adolescents is on the rise despite a lack of data, and more research is needed before such treatment becomes a standard practice, the researchers said. Their results suggest that medications other than antipsychotics might be beneficial for early intervention in patients at risk for developing full-blown schizophrenia.

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31 show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire seeking demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a secret password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, he added.

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31 show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire seeking demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a secret password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, he added.

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

MIAMI — At-home tests that involve self-collected vaginal samples that are sent to a lab for analysis are effective at identifying women with sexually transmitted diseases, suggest findings from a pilot study presented at the annual meeting of the American College of Preventive Medicine.

“We thought maybe we could reach out and get out of the clinic and encourage asymptomatic women to collect samples at home,” said Charlotte A. Gaydos, Dr.P.H., a microbiologist in the division of infectious diseases at Johns Hopkins University, Baltimore.

Surmising that the Internet might be an effective way to promote such at-home tests, the researchers established a Web site (www.iwantthekit.org

Data from 778 samples that had been analyzed as of Jan. 31 show 71 samples (9%) were positive for Chlamydia trachomatis and 12 (1%) were positive for Neisseria gonorrhoeae. Four samples showed coinfection with chlamydia and gonorrhea. Samples collected since September 2006 were tested for Trichomonas vaginalis, and 13 of 115 samples (11%) tested positive.

The test kit includes sterile swabs for collecting vaginal samples and a questionnaire seeking demographics, sexual history, and the participants' opinions about at-home testing and their preferences for methods to receive test results.

“We require two positive assays for a positive diagnosis,” Dr. Gaydos said. Samples are analyzed using nucleic acid amplification tests (NAATs), which are more than 90% sensitive, compared with the 85% sensitivity associated with cultures. “The NAATs are the best tests there are today; they are very powerful,” Dr. Gaydos said.

Participants received their test results via a toll-free number. A study coordinator arranged treatment appointments at a free local clinic for those women with positive test results.

So far, most of the women who tested positive have been treated, Dr. Gaydos noted. All 11 patients with gonorrhea were treated, as were 66 of 69 (96%) chlamydia cases.

Of the 760 participants who identified their race, 70% were black, 22% were white, and the remainder were another race or mixed race. Chlamydia rates were significantly higher among black women, compared with white women (12% vs. 2%).

The participants ranged from 14 to 63 years of age, with an average age of 23 years, but those who tested positive tended to be younger, and the average age at first sex was 15 years, Dr. Gaydos noted.

Positive tests were most common in the 15- to 19-year-olds (16%), followed by 20- to 24-year-olds (8.5%) and 25- to 29-year-olds (8%).

After the researchers controlled for multiple factors including age and race, the strongest risk factors for positive test results were use of birth control, nonconsensual sex, and multiple partners.

In addition, more than 50% of the participants reported a history of STDs; 40% reported a history of chlamydia, and 15% reported a history of gonorrhea.

Results of the questionnaires that accompanied the kits suggest participants were receptive to the idea of at-home STD testing. On a Likert scale of 1 to 5, 96% said that the sampling process was “easy” or “very easy” and 93% said that they would use it again.

Nearly 25% said they preferred to receive results by e-mail, but a secure Web site to provide results is too expensive at this time, Dr. Gaydos said. Under the current protocol, participants calling the toll-free number give the kit number and a secret password that they chose to ensure confidentiality.

Even with the current phone-in method of requesting results, the success of the Web site in recruiting patients for home sampling and in treating those who test positive is encouraging, he added.

A test kit for men was recently developed, and it is promoted on www.iwantthekit.org

MIAMI — “Dusting,” or inhaling gas from computer keyboard cleaner in order to become high, is a practice that is becoming alarmingly popular among adolescents, Dr. Robin McFee said at the annual meeting of the American College of Preventive Medicine.

Using inhalants to get high is nothing new, said Dr. McFee, a toxicologist and adolescent health expert at the State University of New York in Stony Brook, and a toxicologist at the Long Island Regional Poison & Drug Information Center. However, what is new is the use of compressed-air computer keyboard cleaners as euphoriants. Dust-Off (hence the term “dusting”) and other brands of computer keyboard cleaning products are sold in pressurized cans for about $5 and contain freon propellant/refrigerants, usually difluoroethane or tetrafluoroethane. These are not regulated by the Food and Drug Administration.

Contrary to the popular perception among many teenagers, inhalants are not low risk. Even after a single use, the toxins contained in products such as Dust-Off have been associated with death. Data from cases of dusting reported to the poison control center suggest that a fifth of dusters die after their first use, Dr. McFee said.

“We can't predict who is going to die from one of these drugs,” she said. “It is a Russian roulette effect,” a fact that presents a challenge to health care providers who must translate the extreme dangers for an adolescent mind that thinks concretely and nonconsequentially. Long-term morbidity from acute and chronic use of inhalants includes impaired learning, labile emotion, and decreased memory. Inhalants can impair development long after the child has stopped abusing inhalants.

A common misunderstanding among teenagers is that getting high from computer keyboard cleaners is not drug abuse. “That is the perception of every adolescent that I have worked with who has dusted,” Dr. McFee said. “They say that the products are air, not drugs. But they are wrong. They are inhaling a gas.” That gas immediately replaces the air in the user's lungs and is rapidly absorbed, creating an anesthetic effect. The adverse effects are exerted primarily on the heart and brain.

Clinical signs associated with dusting include frostbite and asthmalike symptoms. When treating a suspected user who has pulmonary symptoms, remember that patients who use asthma medications will be more sensitive to the catecholaminergic medications that are the first-line treatment for shortness of breath and bronchospasms, Dr. McFee said in an interview.

In low concentrations, the gases in the keyboard cleaners can cause transient irritation of the eyes, nose, and throat, so frequent use of eyedrops may be a sign of dusting, Dr. McFee noted. The products also can cause headaches, heart palpitations, and light-headedness.

If enough of the gas is absorbed, it can lead to ventricular dysrhythmias, pulmonary edema, cardiac arrest, and sudden death. It's difficult to predict what dose and what frequency of dusting are lethal, Dr. McFee said.

Dr. McFee presented data collected by the Long Island Regional Poison & Drug Information Center that showed a total of 34 cases of poisoning caused by inhaling Dust-Off or a similar product. Five cases per year were reported from 2000 to 2004, but that number nearly doubled to nine cases in 2005 alone. The patients ranged in age from 4 to 48 years, with an average age of 17 years. Five of these dusters died, and 10% suffered significant multisystem damage as a result of dusting.

Multiply these numbers by 70 poison control centers across the country with similar data, Dr. McFee said.

“Statistics are like bikinis; what they reveal is interesting, but what they hide is essential,” she said.

The numbers recorded by poison control centers do not include those who dusted but survived. They may have suffered headaches, red eyes, and vomiting, but these cases aren't reflected in public health poison control data.

Anticipatory guidance and awareness are key to preventing inhalant abuse. “We need to make the most of opportunities to identify and discuss health risks, including inhalant use,” Dr. McFee said.

“Take time to be with [young patients] one on one, build a trust relationship, and provide information about inhalant use and abuse,” she said in an interview.

MIAMI — “Dusting,” or inhaling gas from computer keyboard cleaner in order to become high, is a practice that is becoming alarmingly popular among adolescents, Dr. Robin McFee said at the annual meeting of the American College of Preventive Medicine.

Using inhalants to get high is nothing new, said Dr. McFee, a toxicologist and adolescent health expert at the State University of New York in Stony Brook, and a toxicologist at the Long Island Regional Poison & Drug Information Center. However, what is new is the use of compressed-air computer keyboard cleaners as euphoriants. Dust-Off (hence the term “dusting”) and other brands of computer keyboard cleaning products are sold in pressurized cans for about $5 and contain freon propellant/refrigerants, usually difluoroethane or tetrafluoroethane. These are not regulated by the Food and Drug Administration.

Contrary to the popular perception among many teenagers, inhalants are not low risk. Even after a single use, the toxins contained in products such as Dust-Off have been associated with death. Data from cases of dusting reported to the poison control center suggest that a fifth of dusters die after their first use, Dr. McFee said.

“We can't predict who is going to die from one of these drugs,” she said. “It is a Russian roulette effect,” a fact that presents a challenge to health care providers who must translate the extreme dangers for an adolescent mind that thinks concretely and nonconsequentially. Long-term morbidity from acute and chronic use of inhalants includes impaired learning, labile emotion, and decreased memory. Inhalants can impair development long after the child has stopped abusing inhalants.

A common misunderstanding among teenagers is that getting high from computer keyboard cleaners is not drug abuse. “That is the perception of every adolescent that I have worked with who has dusted,” Dr. McFee said. “They say that the products are air, not drugs. But they are wrong. They are inhaling a gas.” That gas immediately replaces the air in the user's lungs and is rapidly absorbed, creating an anesthetic effect. The adverse effects are exerted primarily on the heart and brain.

Clinical signs associated with dusting include frostbite and asthmalike symptoms. When treating a suspected user who has pulmonary symptoms, remember that patients who use asthma medications will be more sensitive to the catecholaminergic medications that are the first-line treatment for shortness of breath and bronchospasms, Dr. McFee said in an interview.

In low concentrations, the gases in the keyboard cleaners can cause transient irritation of the eyes, nose, and throat, so frequent use of eyedrops may be a sign of dusting, Dr. McFee noted. The products also can cause headaches, heart palpitations, and light-headedness.

If enough of the gas is absorbed, it can lead to ventricular dysrhythmias, pulmonary edema, cardiac arrest, and sudden death. It's difficult to predict what dose and what frequency of dusting are lethal, Dr. McFee said.

Dr. McFee presented data collected by the Long Island Regional Poison & Drug Information Center that showed a total of 34 cases of poisoning caused by inhaling Dust-Off or a similar product. Five cases per year were reported from 2000 to 2004, but that number nearly doubled to nine cases in 2005 alone. The patients ranged in age from 4 to 48 years, with an average age of 17 years. Five of these dusters died, and 10% suffered significant multisystem damage as a result of dusting.

Multiply these numbers by 70 poison control centers across the country with similar data, Dr. McFee said.

“Statistics are like bikinis; what they reveal is interesting, but what they hide is essential,” she said.

The numbers recorded by poison control centers do not include those who dusted but survived. They may have suffered headaches, red eyes, and vomiting, but these cases aren't reflected in public health poison control data.

Anticipatory guidance and awareness are key to preventing inhalant abuse. “We need to make the most of opportunities to identify and discuss health risks, including inhalant use,” Dr. McFee said.

“Take time to be with [young patients] one on one, build a trust relationship, and provide information about inhalant use and abuse,” she said in an interview.

MIAMI — “Dusting,” or inhaling gas from computer keyboard cleaner in order to become high, is a practice that is becoming alarmingly popular among adolescents, Dr. Robin McFee said at the annual meeting of the American College of Preventive Medicine.

Using inhalants to get high is nothing new, said Dr. McFee, a toxicologist and adolescent health expert at the State University of New York in Stony Brook, and a toxicologist at the Long Island Regional Poison & Drug Information Center. However, what is new is the use of compressed-air computer keyboard cleaners as euphoriants. Dust-Off (hence the term “dusting”) and other brands of computer keyboard cleaning products are sold in pressurized cans for about $5 and contain freon propellant/refrigerants, usually difluoroethane or tetrafluoroethane. These are not regulated by the Food and Drug Administration.

Contrary to the popular perception among many teenagers, inhalants are not low risk. Even after a single use, the toxins contained in products such as Dust-Off have been associated with death. Data from cases of dusting reported to the poison control center suggest that a fifth of dusters die after their first use, Dr. McFee said.

“We can't predict who is going to die from one of these drugs,” she said. “It is a Russian roulette effect,” a fact that presents a challenge to health care providers who must translate the extreme dangers for an adolescent mind that thinks concretely and nonconsequentially. Long-term morbidity from acute and chronic use of inhalants includes impaired learning, labile emotion, and decreased memory. Inhalants can impair development long after the child has stopped abusing inhalants.

A common misunderstanding among teenagers is that getting high from computer keyboard cleaners is not drug abuse. “That is the perception of every adolescent that I have worked with who has dusted,” Dr. McFee said. “They say that the products are air, not drugs. But they are wrong. They are inhaling a gas.” That gas immediately replaces the air in the user's lungs and is rapidly absorbed, creating an anesthetic effect. The adverse effects are exerted primarily on the heart and brain.

Clinical signs associated with dusting include frostbite and asthmalike symptoms. When treating a suspected user who has pulmonary symptoms, remember that patients who use asthma medications will be more sensitive to the catecholaminergic medications that are the first-line treatment for shortness of breath and bronchospasms, Dr. McFee said in an interview.

In low concentrations, the gases in the keyboard cleaners can cause transient irritation of the eyes, nose, and throat, so frequent use of eyedrops may be a sign of dusting, Dr. McFee noted. The products also can cause headaches, heart palpitations, and light-headedness.

If enough of the gas is absorbed, it can lead to ventricular dysrhythmias, pulmonary edema, cardiac arrest, and sudden death. It's difficult to predict what dose and what frequency of dusting are lethal, Dr. McFee said.

Dr. McFee presented data collected by the Long Island Regional Poison & Drug Information Center that showed a total of 34 cases of poisoning caused by inhaling Dust-Off or a similar product. Five cases per year were reported from 2000 to 2004, but that number nearly doubled to nine cases in 2005 alone. The patients ranged in age from 4 to 48 years, with an average age of 17 years. Five of these dusters died, and 10% suffered significant multisystem damage as a result of dusting.

Multiply these numbers by 70 poison control centers across the country with similar data, Dr. McFee said.

“Statistics are like bikinis; what they reveal is interesting, but what they hide is essential,” she said.

The numbers recorded by poison control centers do not include those who dusted but survived. They may have suffered headaches, red eyes, and vomiting, but these cases aren't reflected in public health poison control data.

Anticipatory guidance and awareness are key to preventing inhalant abuse. “We need to make the most of opportunities to identify and discuss health risks, including inhalant use,” Dr. McFee said.

“Take time to be with [young patients] one on one, build a trust relationship, and provide information about inhalant use and abuse,” she said in an interview.