Jane Salodof MacNeil

SAN FRANCISCO — One in four consecutive acute ischemic stroke patients displayed immediate improvement within a day of receiving intra-arterial thrombolytic treatment, the investigator of a retrospective 108-patient study reported at the 32nd International Stroke Conference.

Faster time to treatment, greater reperfusion, and good pial collateral formation distinguished the 26 patients (24.5%) who displayed the “Lazarus phenomenon” from those who did not make rapid recoveries, according to a poster presented by Dr. Gregory A. Christoforidis and his colleagues.

“Some people improve even on the table after you dissolve the clot,” Dr. Christoforidis, an interventional radiologist at Ohio State University, Columbus, said Feb. 8 at the meeting, which was sponsored by the American Stroke Association. This improved condition disrupted the procedure in some cases, he said, as they started to move limbs that had been immobilized.

All patients in the study underwent intra-arterial thrombolytic treatment within 6 hours of symptom onset. The investigators defined the “Lazarus phenomenon” as a decrease in the National Institutes of Health Stroke scale (NIHSS) score by at least 50% within the first 24 hours after treatment.

The 49 women and 59 men in the study presented with a median NIHSS score of 16. Lazarus phenomenon patients improved a median of 10 points during the first 24 hours.

Although intra-arterial treatment has a longer time window than the 0- to 3-hour standard for intravenous treatment with clot-busting drugs, time to treatment was one of three significant factors favoring the Lazarus phenomenon in a multivariate analysis. Most patients in the study were treated between 3 and 6 hours after onset of symptoms. Those who recovered rapidly were treated within 198 minutes on average vs. 299 minutes for the others.

Nearly all the Lazarus phenomenon patients (92.3%) had good pial collateral formation vs. 59.7% of the other patients. The investigators scored pial collaterals on the basis of angiography. They said the study suggests that patients with a large ischemic penumbra, as evidenced by greater pial collateral formation, are most likely to benefit from reperfusion.

Nearly half the patients with 50% or greater reperfusion experienced the Lazarus phenomenon. It was not seen in any patients with poor reperfusion and poor pial collateral formation.

None of the other factors studied—systolic blood pressure, admitting glucose levels, admitting platelet levels, site of occlusion thrombolytic agent, and age—was significant in predicting rapid recovery.

Nearly half the patients with 50% or greater reperfusion experienced rapid recovery. DR. CHRISTOFORIDIS

SAN FRANCISCO — One in four consecutive acute ischemic stroke patients displayed immediate improvement within a day of receiving intra-arterial thrombolytic treatment, the investigator of a retrospective 108-patient study reported at the 32nd International Stroke Conference.

Faster time to treatment, greater reperfusion, and good pial collateral formation distinguished the 26 patients (24.5%) who displayed the “Lazarus phenomenon” from those who did not make rapid recoveries, according to a poster presented by Dr. Gregory A. Christoforidis and his colleagues.

“Some people improve even on the table after you dissolve the clot,” Dr. Christoforidis, an interventional radiologist at Ohio State University, Columbus, said Feb. 8 at the meeting, which was sponsored by the American Stroke Association. This improved condition disrupted the procedure in some cases, he said, as they started to move limbs that had been immobilized.

All patients in the study underwent intra-arterial thrombolytic treatment within 6 hours of symptom onset. The investigators defined the “Lazarus phenomenon” as a decrease in the National Institutes of Health Stroke scale (NIHSS) score by at least 50% within the first 24 hours after treatment.

The 49 women and 59 men in the study presented with a median NIHSS score of 16. Lazarus phenomenon patients improved a median of 10 points during the first 24 hours.

Although intra-arterial treatment has a longer time window than the 0- to 3-hour standard for intravenous treatment with clot-busting drugs, time to treatment was one of three significant factors favoring the Lazarus phenomenon in a multivariate analysis. Most patients in the study were treated between 3 and 6 hours after onset of symptoms. Those who recovered rapidly were treated within 198 minutes on average vs. 299 minutes for the others.

Nearly all the Lazarus phenomenon patients (92.3%) had good pial collateral formation vs. 59.7% of the other patients. The investigators scored pial collaterals on the basis of angiography. They said the study suggests that patients with a large ischemic penumbra, as evidenced by greater pial collateral formation, are most likely to benefit from reperfusion.

Nearly half the patients with 50% or greater reperfusion experienced the Lazarus phenomenon. It was not seen in any patients with poor reperfusion and poor pial collateral formation.

None of the other factors studied—systolic blood pressure, admitting glucose levels, admitting platelet levels, site of occlusion thrombolytic agent, and age—was significant in predicting rapid recovery.

Nearly half the patients with 50% or greater reperfusion experienced rapid recovery. DR. CHRISTOFORIDIS

SAN FRANCISCO — One in four consecutive acute ischemic stroke patients displayed immediate improvement within a day of receiving intra-arterial thrombolytic treatment, the investigator of a retrospective 108-patient study reported at the 32nd International Stroke Conference.

Faster time to treatment, greater reperfusion, and good pial collateral formation distinguished the 26 patients (24.5%) who displayed the “Lazarus phenomenon” from those who did not make rapid recoveries, according to a poster presented by Dr. Gregory A. Christoforidis and his colleagues.

“Some people improve even on the table after you dissolve the clot,” Dr. Christoforidis, an interventional radiologist at Ohio State University, Columbus, said Feb. 8 at the meeting, which was sponsored by the American Stroke Association. This improved condition disrupted the procedure in some cases, he said, as they started to move limbs that had been immobilized.

All patients in the study underwent intra-arterial thrombolytic treatment within 6 hours of symptom onset. The investigators defined the “Lazarus phenomenon” as a decrease in the National Institutes of Health Stroke scale (NIHSS) score by at least 50% within the first 24 hours after treatment.

The 49 women and 59 men in the study presented with a median NIHSS score of 16. Lazarus phenomenon patients improved a median of 10 points during the first 24 hours.

Although intra-arterial treatment has a longer time window than the 0- to 3-hour standard for intravenous treatment with clot-busting drugs, time to treatment was one of three significant factors favoring the Lazarus phenomenon in a multivariate analysis. Most patients in the study were treated between 3 and 6 hours after onset of symptoms. Those who recovered rapidly were treated within 198 minutes on average vs. 299 minutes for the others.

Nearly all the Lazarus phenomenon patients (92.3%) had good pial collateral formation vs. 59.7% of the other patients. The investigators scored pial collaterals on the basis of angiography. They said the study suggests that patients with a large ischemic penumbra, as evidenced by greater pial collateral formation, are most likely to benefit from reperfusion.

Nearly half the patients with 50% or greater reperfusion experienced the Lazarus phenomenon. It was not seen in any patients with poor reperfusion and poor pial collateral formation.

None of the other factors studied—systolic blood pressure, admitting glucose levels, admitting platelet levels, site of occlusion thrombolytic agent, and age—was significant in predicting rapid recovery.

Nearly half the patients with 50% or greater reperfusion experienced rapid recovery. DR. CHRISTOFORIDIS

TUCSON, ARIZ. — A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe said patients who were randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission. “We can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was done.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

Therefore, the investigators recruited oncology nurses to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

Initially, one nurse worked full time in a pilot study testing the model, but it was “too much,” so nurses worked half-time in the randomized trial, he said.

Selection and training of nurses without a psychiatric background was also a challenge. “We had a core of three nurses who did treatment, but one of them could not do it and had to leave,” he said.

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is often not detected in cancer patients, or, if recognized, is discounted as a normal response to having cancer. DR. SHARPE

TUCSON, ARIZ. — A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe said patients who were randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission. “We can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was done.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

Therefore, the investigators recruited oncology nurses to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

Initially, one nurse worked full time in a pilot study testing the model, but it was “too much,” so nurses worked half-time in the randomized trial, he said.

Selection and training of nurses without a psychiatric background was also a challenge. “We had a core of three nurses who did treatment, but one of them could not do it and had to leave,” he said.

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is often not detected in cancer patients, or, if recognized, is discounted as a normal response to having cancer. DR. SHARPE

TUCSON, ARIZ. — A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe said patients who were randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission. “We can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was done.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

Therefore, the investigators recruited oncology nurses to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

Initially, one nurse worked full time in a pilot study testing the model, but it was “too much,” so nurses worked half-time in the randomized trial, he said.

Selection and training of nurses without a psychiatric background was also a challenge. “We had a core of three nurses who did treatment, but one of them could not do it and had to leave,” he said.

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is often not detected in cancer patients, or, if recognized, is discounted as a normal response to having cancer. DR. SHARPE

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnograph.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they didn't get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will die early on.”

Dr. Somers is a consultant for Respironics and received an honorarium from the ResMed Foundation, which funded the study. He noted that it follows earlier research at the Mayo Clinic that showed an association between obstructive sleep apnea and atrial fibrillation.

In one study, he and his coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004; 110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with 79 patients who did not have the sleep disorder. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, looking just at the 25 apnea patients who received no treatment, the investigators found nocturnal oxygen saturation fell to lower levels in patients who had a recurrence of atrial fibrillation.

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnograph.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they didn't get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will die early on.”

Dr. Somers is a consultant for Respironics and received an honorarium from the ResMed Foundation, which funded the study. He noted that it follows earlier research at the Mayo Clinic that showed an association between obstructive sleep apnea and atrial fibrillation.

In one study, he and his coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004; 110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with 79 patients who did not have the sleep disorder. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, looking just at the 25 apnea patients who received no treatment, the investigators found nocturnal oxygen saturation fell to lower levels in patients who had a recurrence of atrial fibrillation.

SCOTTSDALE, ARIZ. — Obesity and obstructive sleep apnea are independent risk factors for atrial fibrillation in patients younger than 65 years of age, but not in older patients, according to a retrospective cohort study of 3,542 people who had sleep studies at the Mayo Clinic in Rochester, Minn.

Heart failure was the only independent predictor of new-onset atrial fibrillation for people 65 years of age and older in the study, which followed patients a mean of 4.7 years after an initial polysomnograph.

“The ability of sleep apnea to predict the development of atrial fibrillation was dependent on the age of the patient. If they were more than 65, and they were in sinus rhythm when you did the sleep study, they didn't get atrial fibrillation,” Dr. Virend K. Somers, a coinvestigator, said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

None of the patients reviewed had atrial fibrillation before or at the time of the screenings, conducted from 1987 to 2003, for possible sleep disorders. All told, 133 people developed atrial fibrillation at some point after undergoing polysomnography (J. Am. Coll. Cardiol. 2007;49:565–71).

Obstructive sleep apnea was diagnosed in 2,626 people (74%), and the investigators reported it was a strong predictor (hazard ratio 2.18) of future atrial fibrillation. A total of 4.3% of patients with obstructive sleep apnea but only 2.1% without the disorder were subsequently diagnosed with atrial fibrillation.

An age-stratified analysis showed patients younger than 65 years were more vulnerable to atrial fibrillation, however, and had more risk factors. The most significant was lower oxygen levels at night (hazard ratio 3.29), but age (2.04), male gender (2.66), coronary artery disease (2.66), and body mass index (1.07) also were predictors. In older patients, heart failure had a hazard ratio of 7.68.

Why the older patients were less susceptible to atrial fibrillation is unclear, according to the authors. Dr. Somers, a professor of medicine at the Mayo Clinic, speculated that the older patients probably had undiagnosed apnea for many years.

“If you have sleep apnea and you last to 65–70 years, you are going to be okay—you are going to live longer,” he said. “But if you are susceptible to the damage that sleep apnea does to your cardiovascular system, you will die early on.”

Dr. Somers is a consultant for Respironics and received an honorarium from the ResMed Foundation, which funded the study. He noted that it follows earlier research at the Mayo Clinic that showed an association between obstructive sleep apnea and atrial fibrillation.

In one study, he and his coinvestigators found obstructive sleep apnea was “strikingly more prevalent” (odds ratio 2.19) in atrial fibrillation patients than in general cardiology patients. About half (49%) of 151 patients who underwent electrocardioversion for atrial fibrillation had obstructive sleep apnea vs. about a third (32%) of 312 patients treated for other heart conditions (Circulation 2004; 110:364–7).

In a study of patients who underwent electrocardioversion, Dr. Somers' group found atrial fibrillation was more likely to recur if obstructive sleep apnea was not treated (Circulation 2003;107:2589–94). It compared 39 patients with obstructive sleep apnea with 79 patients who did not have the sleep disorder. Within 12 months, 82% of 27 untreated or inadequately treated apnea patients had their apnea recur, vs. 42% of 12 apnea patients treated with continuous positive airway pressure and 53% of the control group.

Dr. Somers noted that within the apnea population, risk doubled when the condition went untreated. Moreover, looking just at the 25 apnea patients who received no treatment, the investigators found nocturnal oxygen saturation fell to lower levels in patients who had a recurrence of atrial fibrillation.

TUCSON, ARIZ. – A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe reported that patients randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission.

“That tells us we can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was conducted.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

“We still have the view of some primary care doctors that if you've got cancer, you've got depression–that it's normal,” he said.

Therefore, the investigators recruited oncology nurses in an attempt to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

One nurse worked full time in a pilot study testing the model. A full day of depression and cancer care turned out to be “too much,” Dr. Sharpe said. Therefore, nurses worked half-time in the randomized trial.

Selection and training of nurses without a psychiatric background was also a challenge. “We had problems. We recruited people who could not do it,” Dr. Sharpe said. “We had a core of three nurses who did treatment. One could not do it and had to leave.”

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is poorly managed in cancer patients. It is associated with nonadherence to cancer treatment. DR. SHARPE

ELSEVIER GLOBAL MEDICAL NEWS

TUCSON, ARIZ. – A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe reported that patients randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission.

“That tells us we can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was conducted.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

“We still have the view of some primary care doctors that if you've got cancer, you've got depression–that it's normal,” he said.

Therefore, the investigators recruited oncology nurses in an attempt to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

One nurse worked full time in a pilot study testing the model. A full day of depression and cancer care turned out to be “too much,” Dr. Sharpe said. Therefore, nurses worked half-time in the randomized trial.

Selection and training of nurses without a psychiatric background was also a challenge. “We had problems. We recruited people who could not do it,” Dr. Sharpe said. “We had a core of three nurses who did treatment. One could not do it and had to leave.”

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is poorly managed in cancer patients. It is associated with nonadherence to cancer treatment. DR. SHARPE

ELSEVIER GLOBAL MEDICAL NEWS

TUCSON, ARIZ. – A psychiatric intervention conducted by specially trained oncology nurses significantly reduced depression for cancer patients enrolled in a clinical trial presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Michael Sharpe reported that patients randomized to problem-solving therapy reached lower mean scores on the Symptom Checklist-20 (SCL-20) and were more likely to achieve a 50% reduction in clinical symptoms, compared with patients given optimized usual care. The randomized group also had twice the rate of complete remission.

“That tells us we can make a difference in depression in cancer patients with this kind of model,” said Dr. Sharpe, a professor of psychological medicine and symptoms research at the University of Edinburgh where the 200-patient trial was conducted.

Depression is common but poorly managed in cancer patients, according to Dr. Sharpe. It is associated with nonadherence to cancer treatment, increased medical costs, and suicide, he said. Yet it is often not detected or, if recognized, discounted as a normal response to having cancer.

“We still have the view of some primary care doctors that if you've got cancer, you've got depression–that it's normal,” he said.

Therefore, the investigators recruited oncology nurses in an attempt to integrate depression care into cancer care. A psychiatrist supervised the nurses, who coordinated drug treatment, delivered psychological treatment, and monitored patient progress.

As described by Dr. Sharpe, the psychological component was a problem-solving therapy in which the patients would list cancer and noncancer concerns. They would choose one concern to focus on with the nurse, identifying what a solution would look like and brainstorming on how to achieve it. Next, they would choose and try out a strategy.

One nurse worked full time in a pilot study testing the model. A full day of depression and cancer care turned out to be “too much,” Dr. Sharpe said. Therefore, nurses worked half-time in the randomized trial.

Selection and training of nurses without a psychiatric background was also a challenge. “We had problems. We recruited people who could not do it,” Dr. Sharpe said. “We had a core of three nurses who did treatment. One could not do it and had to leave.”

The trial population was drawn from a pool of patients who underwent computerized screening for depression before consultation with their oncologists. Depression diagnoses were based on subsequent structured clinical interviews of patients who scored above 14 on the Hospital Anxiety and Depression Scale.

Two hundred patients were randomized: 99 to optimized usual care and 101 to optimized usual care plus the Symptom Management Research Trials (SMaRT) intervention by the oncology nurses. Dr. Sharpe noted that primary care physicians were notified of all depression diagnoses and could prescribe antidepressants to patients in both groups.

Breast cancer was the most common malignancy, accounting for more than 40% of the patients enrolled. The study population was generally female with an average age of 56 years. About two-thirds were disease free, and more than 80% were visiting oncologists for follow-up care after completing cancer therapy.

Data analysis was done at 3 months' follow-up for all 99 usual-care patients and 97 who received the added intervention (4 patients, including 2 who died, were excluded because of incomplete data).

The intervention group had lower mean SCL-20 scores, compared with the usual-care group: 1.25 vs. 1.54. More than half (53%) of the intervention group achieved a 50% clinical reduction of depression symptoms compared with about a third (34%) of the control group. Twice as many had a complete remission on the SCL-20: 29% vs. 14%. Remission rates were also significantly higher based on structured clinical interviews: 67% vs. 45%, respectively.

Although he did not report statistics in detail, Dr. Sharpe said the effects “were maintained and possibly increased” at 6 months. The next step, he said, will be to duplicate the study with more nurses and patients at multiple centers.

Depression is poorly managed in cancer patients. It is associated with nonadherence to cancer treatment. DR. SHARPE

ELSEVIER GLOBAL MEDICAL NEWS

SCOTTSDALE, ARIZ. – Even mild sleep disorders have the potential to affect fetal outcomes during pregnancy, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Recent research suggests that obstructive sleep apnea might impact hypertension in pregnant women with preeclampsia, according to Dr. Harding, professor of medicine at the University of Alabama, Birmingham, and medical director of the Sleep/Wake Disorders Center there.

Other studies cited by Dr. Harding show a higher risk of lower-birth-weight babies in women who work night shifts, and increases in labor duration and in cesarean section rates when women sleep poorly.

Potential relationships between sleep and pregnancy are “a really ripe area” in need of more research, she noted.

Dr. Harding cited a Swedish study of 502 singleton pregnancies that diagnosed hypertension in 14% of 113 snorers but in only 6% of 389 nonsnorers (Chest 2000;117:137–41). Preeclampsia also was significantly more prevalent, occurring in 10% of snorers vs. 4% of women who did not snore.

The investigators concluded that habitual snoring is an independent predictor of hypertension (odds ratio 2.03) and growth retardation (OR 3.45). Dr. Harding noted that snorers' babies were significantly more likely to have Apgar scores of 7 or lower at 1 minute after birth (12.4% vs. 3.6%) and to be small for gestational age (7.1% vs. 2.6%). Only 4% of women snored before becoming pregnant, whereas 23% snored during their final week of pregnancy.

Another study cited by Dr. Harding delivered continuous positive airways pressure (CPAP) to 11 pregnant women with severe preeclampsia and findings of upper airway resistance syndrome (Am. J. Respir. Crit. Care Med. 2000;162:252–7). CPAP reduced blood pressure in these women.

The shift-work study reviewed 41,150 pregnancies in a Danish database (Am. J. Obstet. Gynecol. 2004;191:285–91). Dr. Harding said women on permanent night shifts had a higher risk of post-term birth (OR 1.35) and delivering a low-birth-weight baby at term (OR 1.80).

She also cited an American study of 131 women in their ninth month of pregnancy (Am. J. Obstet. Gynecol. 2004;191:2041–6). Women who slept fewer than 6 hours each night had longer durations of labor (29 hours vs. 18 hours) and a higher cesarean rate (37% vs. 11%), compared with those who slept more hours. Longer labors and higher cesarean rates also were linked with disrupted sleep.

Although these studies are not conclusive, Dr. Harding said the evidence so far is sufficiently strong that physicians should consider screening pregnant women for obstructive sleep apnea, especially when hypertension is an issue. She noted that CPAP requirements of women treated for obstructive sleep apnea could change during pregnancy and need to be monitored.

Treating two other sleep disorders–restless leg syndrome (RLS) and narcolepsy–is problematic because modafinil and medications used in treating these disorders are contraindicated during pregnancy, according to Dr. Harding. Pregnancy is a risk factor for development of RLS. Up to a third of pregnant women will have RLS symptoms, she said, most often during the last trimester. Symptoms usually resolve within 10 days of giving birth.

Dr. Harding recommended educating women being treated for RLS or other sleep disorders about the need to discontinue modafinil, stimulants, and other medications prior to becoming pregnant. She called on physicians to assess risks, such as patients' driving when drowsy, if drug therapies are stopped. “Off medication, they may have significant problems,” she said.

To prevent RLS during pregnancy, she suggested that all women take folate supplements. Also, about 30% of women are iron deficient at the outset of their pregnancies, she said; third-trimester RLS has been linked to low serum folate and ferritin levels.

Consider testing pregnant women for obstructive sleep apnea, especially when hypertension is an issue. DR. HARDING

SCOTTSDALE, ARIZ. – Even mild sleep disorders have the potential to affect fetal outcomes during pregnancy, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Recent research suggests that obstructive sleep apnea might impact hypertension in pregnant women with preeclampsia, according to Dr. Harding, professor of medicine at the University of Alabama, Birmingham, and medical director of the Sleep/Wake Disorders Center there.

Other studies cited by Dr. Harding show a higher risk of lower-birth-weight babies in women who work night shifts, and increases in labor duration and in cesarean section rates when women sleep poorly.

Potential relationships between sleep and pregnancy are “a really ripe area” in need of more research, she noted.

Dr. Harding cited a Swedish study of 502 singleton pregnancies that diagnosed hypertension in 14% of 113 snorers but in only 6% of 389 nonsnorers (Chest 2000;117:137–41). Preeclampsia also was significantly more prevalent, occurring in 10% of snorers vs. 4% of women who did not snore.

The investigators concluded that habitual snoring is an independent predictor of hypertension (odds ratio 2.03) and growth retardation (OR 3.45). Dr. Harding noted that snorers' babies were significantly more likely to have Apgar scores of 7 or lower at 1 minute after birth (12.4% vs. 3.6%) and to be small for gestational age (7.1% vs. 2.6%). Only 4% of women snored before becoming pregnant, whereas 23% snored during their final week of pregnancy.

Another study cited by Dr. Harding delivered continuous positive airways pressure (CPAP) to 11 pregnant women with severe preeclampsia and findings of upper airway resistance syndrome (Am. J. Respir. Crit. Care Med. 2000;162:252–7). CPAP reduced blood pressure in these women.

The shift-work study reviewed 41,150 pregnancies in a Danish database (Am. J. Obstet. Gynecol. 2004;191:285–91). Dr. Harding said women on permanent night shifts had a higher risk of post-term birth (OR 1.35) and delivering a low-birth-weight baby at term (OR 1.80).

She also cited an American study of 131 women in their ninth month of pregnancy (Am. J. Obstet. Gynecol. 2004;191:2041–6). Women who slept fewer than 6 hours each night had longer durations of labor (29 hours vs. 18 hours) and a higher cesarean rate (37% vs. 11%), compared with those who slept more hours. Longer labors and higher cesarean rates also were linked with disrupted sleep.

Although these studies are not conclusive, Dr. Harding said the evidence so far is sufficiently strong that physicians should consider screening pregnant women for obstructive sleep apnea, especially when hypertension is an issue. She noted that CPAP requirements of women treated for obstructive sleep apnea could change during pregnancy and need to be monitored.

Treating two other sleep disorders–restless leg syndrome (RLS) and narcolepsy–is problematic because modafinil and medications used in treating these disorders are contraindicated during pregnancy, according to Dr. Harding. Pregnancy is a risk factor for development of RLS. Up to a third of pregnant women will have RLS symptoms, she said, most often during the last trimester. Symptoms usually resolve within 10 days of giving birth.

Dr. Harding recommended educating women being treated for RLS or other sleep disorders about the need to discontinue modafinil, stimulants, and other medications prior to becoming pregnant. She called on physicians to assess risks, such as patients' driving when drowsy, if drug therapies are stopped. “Off medication, they may have significant problems,” she said.

To prevent RLS during pregnancy, she suggested that all women take folate supplements. Also, about 30% of women are iron deficient at the outset of their pregnancies, she said; third-trimester RLS has been linked to low serum folate and ferritin levels.

Consider testing pregnant women for obstructive sleep apnea, especially when hypertension is an issue. DR. HARDING

SCOTTSDALE, ARIZ. – Even mild sleep disorders have the potential to affect fetal outcomes during pregnancy, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Recent research suggests that obstructive sleep apnea might impact hypertension in pregnant women with preeclampsia, according to Dr. Harding, professor of medicine at the University of Alabama, Birmingham, and medical director of the Sleep/Wake Disorders Center there.

Other studies cited by Dr. Harding show a higher risk of lower-birth-weight babies in women who work night shifts, and increases in labor duration and in cesarean section rates when women sleep poorly.

Potential relationships between sleep and pregnancy are “a really ripe area” in need of more research, she noted.

Dr. Harding cited a Swedish study of 502 singleton pregnancies that diagnosed hypertension in 14% of 113 snorers but in only 6% of 389 nonsnorers (Chest 2000;117:137–41). Preeclampsia also was significantly more prevalent, occurring in 10% of snorers vs. 4% of women who did not snore.

The investigators concluded that habitual snoring is an independent predictor of hypertension (odds ratio 2.03) and growth retardation (OR 3.45). Dr. Harding noted that snorers' babies were significantly more likely to have Apgar scores of 7 or lower at 1 minute after birth (12.4% vs. 3.6%) and to be small for gestational age (7.1% vs. 2.6%). Only 4% of women snored before becoming pregnant, whereas 23% snored during their final week of pregnancy.

Another study cited by Dr. Harding delivered continuous positive airways pressure (CPAP) to 11 pregnant women with severe preeclampsia and findings of upper airway resistance syndrome (Am. J. Respir. Crit. Care Med. 2000;162:252–7). CPAP reduced blood pressure in these women.

The shift-work study reviewed 41,150 pregnancies in a Danish database (Am. J. Obstet. Gynecol. 2004;191:285–91). Dr. Harding said women on permanent night shifts had a higher risk of post-term birth (OR 1.35) and delivering a low-birth-weight baby at term (OR 1.80).

She also cited an American study of 131 women in their ninth month of pregnancy (Am. J. Obstet. Gynecol. 2004;191:2041–6). Women who slept fewer than 6 hours each night had longer durations of labor (29 hours vs. 18 hours) and a higher cesarean rate (37% vs. 11%), compared with those who slept more hours. Longer labors and higher cesarean rates also were linked with disrupted sleep.

Although these studies are not conclusive, Dr. Harding said the evidence so far is sufficiently strong that physicians should consider screening pregnant women for obstructive sleep apnea, especially when hypertension is an issue. She noted that CPAP requirements of women treated for obstructive sleep apnea could change during pregnancy and need to be monitored.

Treating two other sleep disorders–restless leg syndrome (RLS) and narcolepsy–is problematic because modafinil and medications used in treating these disorders are contraindicated during pregnancy, according to Dr. Harding. Pregnancy is a risk factor for development of RLS. Up to a third of pregnant women will have RLS symptoms, she said, most often during the last trimester. Symptoms usually resolve within 10 days of giving birth.

Dr. Harding recommended educating women being treated for RLS or other sleep disorders about the need to discontinue modafinil, stimulants, and other medications prior to becoming pregnant. She called on physicians to assess risks, such as patients' driving when drowsy, if drug therapies are stopped. “Off medication, they may have significant problems,” she said.

To prevent RLS during pregnancy, she suggested that all women take folate supplements. Also, about 30% of women are iron deficient at the outset of their pregnancies, she said; third-trimester RLS has been linked to low serum folate and ferritin levels.

Consider testing pregnant women for obstructive sleep apnea, especially when hypertension is an issue. DR. HARDING

SAN FRANCISCO — Risk-benefit ratios, the possibility of voiding dysfunction, the choice of prolapse procedure, and the woman's own priorities are among the factors that need to be considered when deciding whether to combine continence and prolapse procedures, Dr. Linda Brubaker said at a conference sponsored by the Society of Gynecologic Surgeons.

Dr. Brubaker was principal investigator in the Colpopexy and Urinary Reduction Efforts (CARE) trial. The results showed that combining the Burch colposuspension procedure with abdominal sacrocolpopexy significantly reduced the incidence of stress incontinence (N. Engl. J. Med. 2006;354:1557–66).

The trial randomized 157 women to both procedures and 165 to sacrocolpopexy alone. Three months after surgery, stress urinary incontinence was diagnosed in 44% of women who did not have the Burch procedure vs. 24% of women who did. Urge incontinence and serious adverse events were also reduced in the Burch group, but the difference did not reach statistical significance.

Dr. Brubaker, director of the division of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., emphasized that the trial does not apply to all patients. It enrolled only women who were asymptomatic at baseline.

“If you don't put a Burch in, at least a third of your women are going to have stress incontinence, but people who leak are going to leak regardless of the Burch,” commented Dr. Brubaker, professor of obstetrics and gynecology and of urogynecology and urology.

About 75% of all women with advanced prolapse have stress incontinence, you will learn if you carefully question, she said. The accuracy of diagnostic tests is limited, however, and she dismissed as largely ineffective most methods of predicting which patients will develop a problem after surgery.

Widely used terminology can be problematic as well, according to Dr. Brubaker. Patients can be said to have “potential stress incontinence” prior to surgery if they have no symptoms. Once they undergo urodynamic testing, however, either they have urodynamic stress incontinence or they do not. “The terms are not used in the same way,” she emphasized.

Another consideration is that the precise relationship between prolapse and symptoms is not clear, she said, warning that the chance of surgeon error increases with the extent of the prolapse. Overtreatment could lead to retention, she warned, and undertreatment could lead to incontinence.

“There is a delicate balance between voiding dysfunction and incontinence,” she added, discussing her decision not to do a continence procedure in a frail, elderly patient scheduled for colpocleisis. “It is better to err on the incontinence side. When both are present, undertreat the incontinence.”

Dr. Brubaker recommended doing a continence assessment that includes a preoperative evaluation of urinary symptoms, sexual function, and constipation in all patients. The assessment should also entail a discussion of each person's goals and expectations going into surgery. Sometimes you have to make a trade-off with patients who have prolapse, she said, so understanding goals is important.

About 75% of all women with advanced prolapse have stress incontinence. DR. BRUBAKER

SAN FRANCISCO — Risk-benefit ratios, the possibility of voiding dysfunction, the choice of prolapse procedure, and the woman's own priorities are among the factors that need to be considered when deciding whether to combine continence and prolapse procedures, Dr. Linda Brubaker said at a conference sponsored by the Society of Gynecologic Surgeons.

Dr. Brubaker was principal investigator in the Colpopexy and Urinary Reduction Efforts (CARE) trial. The results showed that combining the Burch colposuspension procedure with abdominal sacrocolpopexy significantly reduced the incidence of stress incontinence (N. Engl. J. Med. 2006;354:1557–66).

The trial randomized 157 women to both procedures and 165 to sacrocolpopexy alone. Three months after surgery, stress urinary incontinence was diagnosed in 44% of women who did not have the Burch procedure vs. 24% of women who did. Urge incontinence and serious adverse events were also reduced in the Burch group, but the difference did not reach statistical significance.

Dr. Brubaker, director of the division of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., emphasized that the trial does not apply to all patients. It enrolled only women who were asymptomatic at baseline.

“If you don't put a Burch in, at least a third of your women are going to have stress incontinence, but people who leak are going to leak regardless of the Burch,” commented Dr. Brubaker, professor of obstetrics and gynecology and of urogynecology and urology.

About 75% of all women with advanced prolapse have stress incontinence, you will learn if you carefully question, she said. The accuracy of diagnostic tests is limited, however, and she dismissed as largely ineffective most methods of predicting which patients will develop a problem after surgery.

Widely used terminology can be problematic as well, according to Dr. Brubaker. Patients can be said to have “potential stress incontinence” prior to surgery if they have no symptoms. Once they undergo urodynamic testing, however, either they have urodynamic stress incontinence or they do not. “The terms are not used in the same way,” she emphasized.

Another consideration is that the precise relationship between prolapse and symptoms is not clear, she said, warning that the chance of surgeon error increases with the extent of the prolapse. Overtreatment could lead to retention, she warned, and undertreatment could lead to incontinence.

“There is a delicate balance between voiding dysfunction and incontinence,” she added, discussing her decision not to do a continence procedure in a frail, elderly patient scheduled for colpocleisis. “It is better to err on the incontinence side. When both are present, undertreat the incontinence.”

Dr. Brubaker recommended doing a continence assessment that includes a preoperative evaluation of urinary symptoms, sexual function, and constipation in all patients. The assessment should also entail a discussion of each person's goals and expectations going into surgery. Sometimes you have to make a trade-off with patients who have prolapse, she said, so understanding goals is important.

About 75% of all women with advanced prolapse have stress incontinence. DR. BRUBAKER

SAN FRANCISCO — Risk-benefit ratios, the possibility of voiding dysfunction, the choice of prolapse procedure, and the woman's own priorities are among the factors that need to be considered when deciding whether to combine continence and prolapse procedures, Dr. Linda Brubaker said at a conference sponsored by the Society of Gynecologic Surgeons.

Dr. Brubaker was principal investigator in the Colpopexy and Urinary Reduction Efforts (CARE) trial. The results showed that combining the Burch colposuspension procedure with abdominal sacrocolpopexy significantly reduced the incidence of stress incontinence (N. Engl. J. Med. 2006;354:1557–66).

The trial randomized 157 women to both procedures and 165 to sacrocolpopexy alone. Three months after surgery, stress urinary incontinence was diagnosed in 44% of women who did not have the Burch procedure vs. 24% of women who did. Urge incontinence and serious adverse events were also reduced in the Burch group, but the difference did not reach statistical significance.

Dr. Brubaker, director of the division of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., emphasized that the trial does not apply to all patients. It enrolled only women who were asymptomatic at baseline.

“If you don't put a Burch in, at least a third of your women are going to have stress incontinence, but people who leak are going to leak regardless of the Burch,” commented Dr. Brubaker, professor of obstetrics and gynecology and of urogynecology and urology.

About 75% of all women with advanced prolapse have stress incontinence, you will learn if you carefully question, she said. The accuracy of diagnostic tests is limited, however, and she dismissed as largely ineffective most methods of predicting which patients will develop a problem after surgery.

Widely used terminology can be problematic as well, according to Dr. Brubaker. Patients can be said to have “potential stress incontinence” prior to surgery if they have no symptoms. Once they undergo urodynamic testing, however, either they have urodynamic stress incontinence or they do not. “The terms are not used in the same way,” she emphasized.

Another consideration is that the precise relationship between prolapse and symptoms is not clear, she said, warning that the chance of surgeon error increases with the extent of the prolapse. Overtreatment could lead to retention, she warned, and undertreatment could lead to incontinence.

“There is a delicate balance between voiding dysfunction and incontinence,” she added, discussing her decision not to do a continence procedure in a frail, elderly patient scheduled for colpocleisis. “It is better to err on the incontinence side. When both are present, undertreat the incontinence.”

Dr. Brubaker recommended doing a continence assessment that includes a preoperative evaluation of urinary symptoms, sexual function, and constipation in all patients. The assessment should also entail a discussion of each person's goals and expectations going into surgery. Sometimes you have to make a trade-off with patients who have prolapse, she said, so understanding goals is important.

About 75% of all women with advanced prolapse have stress incontinence. DR. BRUBAKER

SAN FRANCISCO — Fecal incontinence after childbirth is a common, sometimes severe, and underrecognized problem that could be reduced with greater efforts to prevent anal sphincter ruptures, Dr. Michael P. Aronson told attendees at a conference sponsored by the Society of Gynecologic Surgeons.

Attempts to fix the damage after delivery do not work well, according to Dr. Aronson, director of women's health services at the University of Massachusetts, Worcester. Even when surgical repairs of lacerations are deemed successful, many women remain incontinent and some develop new defecatory dysfunction.

“It really matters what happens at the delivery,” he said. “If you can prevent that sphincter rupture, you can prevent a whole field of woes down the line for that patient.”

Dr. Aronson, a professor of obstetrics and gynecology, held up his own institution, a major tertiary care center, as an example of how shining a spotlight on the issue can reduce third- and fourth-degree anal sphincter lacerations.

Officials recognized that they had a problem in the summer of 2003, when the laceration rate was 8%. A year later, the rate was 6%, a reduction Dr. Aronson attributed mostly to better definitions and entering of data. Meanwhile, he noted, an education program also focused attention on the problem.

As of the spring of 2006, he reported, the rate had declined to 2.8%—better than the national standard of 3%. Defining and measuring was crucial, Dr. Aronson said, adding that “the improvement is sustainable.”

He estimated that nationwide, sphincter disruption occurs during 0.5% of vaginal births, a rate that he translated into 150,000 cases each year. If 25% of these new mothers has incontinence as a sequela, he calculated, 37,500 women are affected each year—or one new case every 14 minutes. Moreover, when incontinence occurs after sphincter rupture, he warned, symptoms increase over time.

(Anal sphincter lacerations are not the only cause of fecal incontinence, Dr. Aronson noted. Stretching the pudendal nerve during delivery can also be a contributing factor. In one study, about a third of women without a tear suffered from incontinence 5 years after giving birth.)

Dr. Aronson advocated avoiding midline episiotomy as a way of preventing anal sphincter ruptures. Numerous studies have shown it to be associated with incontinence and sphincter ruptures in up to one-fourth of patients, he said. “Midline episiotomy should be avoided if at all possible.”

Operative delivery is also significantly associated with sphincter ruptures, Dr. Aronson added. He quoted odds ratios ranging from 6.7 with forceps delivery to 2.3 with vacuum delivery.

Moreover, a history of sphincter rupture should be a serious consideration when deciding how to deliver a woman's subsequent children, according to Dr. Aronson. He warned that women who have had a third- or fourth-degree laceration are at higher risk of a new laceration in subsequent births.

Although one large cohort study of 19,000 women reported no increase with a prior history of laceration, he said, other cohort studies and a 24-year review of the Swedish Birth Registry supported increased risk. The relative risk in these studies ranged from 2.5 to 6.5.

Standard surgical repairs of anal sphincter lacerations do not heal well, Dr. Aronson continued. Ultrasound examinations have shown defect rates ranging from 79% after 3 months to 90% after the 1st week in cases that appeared to be on the mend.

“This is a tough repair,” he said. “We all know as surgeons that tension is the enemy of healing. There's tension on this right off the bat.”

When all else fails, turning the patient over to a urogynecologist or colorectal surgeon is not likely to fix the problem, Dr. Aronson added. He cited one study of successful overlapping sphincteroplasty in which 51 patients needed no further surgeries. Yet not one patient was totally continent and 14 developed new defecatory dysfunction over the next 5 years.

“Fecal incontinence is a terrible problem, much more prevalent than you know,” he said. “Our tools to fix it are not good. It is better to prevent it.”

SAN FRANCISCO — Fecal incontinence after childbirth is a common, sometimes severe, and underrecognized problem that could be reduced with greater efforts to prevent anal sphincter ruptures, Dr. Michael P. Aronson told attendees at a conference sponsored by the Society of Gynecologic Surgeons.

Attempts to fix the damage after delivery do not work well, according to Dr. Aronson, director of women's health services at the University of Massachusetts, Worcester. Even when surgical repairs of lacerations are deemed successful, many women remain incontinent and some develop new defecatory dysfunction.

“It really matters what happens at the delivery,” he said. “If you can prevent that sphincter rupture, you can prevent a whole field of woes down the line for that patient.”

Dr. Aronson, a professor of obstetrics and gynecology, held up his own institution, a major tertiary care center, as an example of how shining a spotlight on the issue can reduce third- and fourth-degree anal sphincter lacerations.

Officials recognized that they had a problem in the summer of 2003, when the laceration rate was 8%. A year later, the rate was 6%, a reduction Dr. Aronson attributed mostly to better definitions and entering of data. Meanwhile, he noted, an education program also focused attention on the problem.

As of the spring of 2006, he reported, the rate had declined to 2.8%—better than the national standard of 3%. Defining and measuring was crucial, Dr. Aronson said, adding that “the improvement is sustainable.”

He estimated that nationwide, sphincter disruption occurs during 0.5% of vaginal births, a rate that he translated into 150,000 cases each year. If 25% of these new mothers has incontinence as a sequela, he calculated, 37,500 women are affected each year—or one new case every 14 minutes. Moreover, when incontinence occurs after sphincter rupture, he warned, symptoms increase over time.

(Anal sphincter lacerations are not the only cause of fecal incontinence, Dr. Aronson noted. Stretching the pudendal nerve during delivery can also be a contributing factor. In one study, about a third of women without a tear suffered from incontinence 5 years after giving birth.)

Dr. Aronson advocated avoiding midline episiotomy as a way of preventing anal sphincter ruptures. Numerous studies have shown it to be associated with incontinence and sphincter ruptures in up to one-fourth of patients, he said. “Midline episiotomy should be avoided if at all possible.”

Operative delivery is also significantly associated with sphincter ruptures, Dr. Aronson added. He quoted odds ratios ranging from 6.7 with forceps delivery to 2.3 with vacuum delivery.

Moreover, a history of sphincter rupture should be a serious consideration when deciding how to deliver a woman's subsequent children, according to Dr. Aronson. He warned that women who have had a third- or fourth-degree laceration are at higher risk of a new laceration in subsequent births.

Although one large cohort study of 19,000 women reported no increase with a prior history of laceration, he said, other cohort studies and a 24-year review of the Swedish Birth Registry supported increased risk. The relative risk in these studies ranged from 2.5 to 6.5.

Standard surgical repairs of anal sphincter lacerations do not heal well, Dr. Aronson continued. Ultrasound examinations have shown defect rates ranging from 79% after 3 months to 90% after the 1st week in cases that appeared to be on the mend.

“This is a tough repair,” he said. “We all know as surgeons that tension is the enemy of healing. There's tension on this right off the bat.”

When all else fails, turning the patient over to a urogynecologist or colorectal surgeon is not likely to fix the problem, Dr. Aronson added. He cited one study of successful overlapping sphincteroplasty in which 51 patients needed no further surgeries. Yet not one patient was totally continent and 14 developed new defecatory dysfunction over the next 5 years.

“Fecal incontinence is a terrible problem, much more prevalent than you know,” he said. “Our tools to fix it are not good. It is better to prevent it.”

SAN FRANCISCO — Fecal incontinence after childbirth is a common, sometimes severe, and underrecognized problem that could be reduced with greater efforts to prevent anal sphincter ruptures, Dr. Michael P. Aronson told attendees at a conference sponsored by the Society of Gynecologic Surgeons.

Attempts to fix the damage after delivery do not work well, according to Dr. Aronson, director of women's health services at the University of Massachusetts, Worcester. Even when surgical repairs of lacerations are deemed successful, many women remain incontinent and some develop new defecatory dysfunction.

“It really matters what happens at the delivery,” he said. “If you can prevent that sphincter rupture, you can prevent a whole field of woes down the line for that patient.”

Dr. Aronson, a professor of obstetrics and gynecology, held up his own institution, a major tertiary care center, as an example of how shining a spotlight on the issue can reduce third- and fourth-degree anal sphincter lacerations.

Officials recognized that they had a problem in the summer of 2003, when the laceration rate was 8%. A year later, the rate was 6%, a reduction Dr. Aronson attributed mostly to better definitions and entering of data. Meanwhile, he noted, an education program also focused attention on the problem.

As of the spring of 2006, he reported, the rate had declined to 2.8%—better than the national standard of 3%. Defining and measuring was crucial, Dr. Aronson said, adding that “the improvement is sustainable.”

He estimated that nationwide, sphincter disruption occurs during 0.5% of vaginal births, a rate that he translated into 150,000 cases each year. If 25% of these new mothers has incontinence as a sequela, he calculated, 37,500 women are affected each year—or one new case every 14 minutes. Moreover, when incontinence occurs after sphincter rupture, he warned, symptoms increase over time.

(Anal sphincter lacerations are not the only cause of fecal incontinence, Dr. Aronson noted. Stretching the pudendal nerve during delivery can also be a contributing factor. In one study, about a third of women without a tear suffered from incontinence 5 years after giving birth.)

Dr. Aronson advocated avoiding midline episiotomy as a way of preventing anal sphincter ruptures. Numerous studies have shown it to be associated with incontinence and sphincter ruptures in up to one-fourth of patients, he said. “Midline episiotomy should be avoided if at all possible.”

Operative delivery is also significantly associated with sphincter ruptures, Dr. Aronson added. He quoted odds ratios ranging from 6.7 with forceps delivery to 2.3 with vacuum delivery.

Moreover, a history of sphincter rupture should be a serious consideration when deciding how to deliver a woman's subsequent children, according to Dr. Aronson. He warned that women who have had a third- or fourth-degree laceration are at higher risk of a new laceration in subsequent births.

Although one large cohort study of 19,000 women reported no increase with a prior history of laceration, he said, other cohort studies and a 24-year review of the Swedish Birth Registry supported increased risk. The relative risk in these studies ranged from 2.5 to 6.5.

Standard surgical repairs of anal sphincter lacerations do not heal well, Dr. Aronson continued. Ultrasound examinations have shown defect rates ranging from 79% after 3 months to 90% after the 1st week in cases that appeared to be on the mend.

“This is a tough repair,” he said. “We all know as surgeons that tension is the enemy of healing. There's tension on this right off the bat.”

When all else fails, turning the patient over to a urogynecologist or colorectal surgeon is not likely to fix the problem, Dr. Aronson added. He cited one study of successful overlapping sphincteroplasty in which 51 patients needed no further surgeries. Yet not one patient was totally continent and 14 developed new defecatory dysfunction over the next 5 years.

“Fecal incontinence is a terrible problem, much more prevalent than you know,” he said. “Our tools to fix it are not good. It is better to prevent it.”

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or in starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or in starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

TUCSON, ARIZ. — Apathy is not recognized as a psychiatric disorder, but treating it may improve glycemic control in patients with type 2 diabetes, according to a poster presented at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Prasad R. Padala reported that apathy was highly prevalent in a cross-sectional study of 70 patients with diabetes mellitus who were recruited from various clinics at the Omaha division of the VA (Veterans Affairs) Nebraska Western Iowa Health Care System. Of these, 44 patients (63%) had clinically significant apathy, as defined by a score above 30 on the Apathy Evaluation Scale (AES).

Poor glycemic control was common, too, as 47 patients (67%) had HbA1c values of 7% or more, reported Dr. Padala of the department of psychiatry at the University of Nebraska Medical Center, Omaha.

And patients who met clinical criteria for apathy were more likely to have poor glycemic control than were those who did not.

Investigators found 34 (77%) of the 44 patients who met criteria for clinically significant apathy also met the criterion for poor glycemic control. In comparison, just half of 26 patients who did not meet the clinical definition of apathy were failing to control their glucose levels. The difference was statistically significant.

Conversely, the 23 patients with good glycemic control also were less likely to have clinically significant apathy: Just 10 of them (43%) scored high on the apathy scale. The patients studied were 91% male with a mean age of 57.3 years and a mean HbA1c of 7.9%.

“Apathy syndrome is a lack of motivation—a lack of drive—that typically is not explained by just depression or cognitive decline or delirium,” Dr. Padala said in an interview. “And this has significant impact on the outcomes of chronic illness.”

Apathy is not a disorder according to the DSM-IV, he added, but psychiatrists are debating whether it should be defined as one in the next edition.

“What we feel is, apathy transcends diagnosis. This could be a dimension of psychiatry that goes through different clinical diagnoses,” Dr. Padala said, noting that apathy has been found in patients with bipolar and anxiety disorders, and also is common in chronic medical conditions such as parkinsonism.

Available treatments include methylphenidate, modafinil (Provigil), and a form of group therapy called medical crisis counseling, according to Dr. Padala. He said he works with an endocrinologist who has learned how to screen patients with poor glycemic control for apathy and has started to treat them with methylphenidate.

For easy screening in endocrinology practices, Dr. Padala recommended asking the following four questions on apathy from the Neuropsychiatric Inventory (Neurology 1994;44:2308–14):

▸ Has the patient lost interest in the world around him/her?

▸ Has he/she lost interest in doing things, or in starting new activities?

▸ Is he/she more difficult to engage in conversation or in doing chores?

▸ Is the patient apathetic or indifferent?

“You have to ask [about apathy]. If you don't ask, people are not going to tell,” Dr. Padala said.

PARIS — Methylphenidate really can keep people with attention-deficit hyperactivity disorder on the straight and narrow, according to a study that was conducted in the Netherlands.

Dr. Joris C. Verster and his colleagues at the University of Utrecht Institute for Pharmaceutical Sciences, the Netherlands, compared the driving skills of 18 patients when they took their methylphenidate (Ritalin) with their ability when they went off medication.

Each patient made two 100-kilometer round trips in normal traffic. The protocol called for maintaining a steady speed of 95 km/hour while staying in the right lane. Twice each second, a camera on the automobile roof recorded the distance to the center of the road. The patients, aged 21–30 years, were able to maintain a steady speed on both trips, but they weaved significantly more when they were not medicated, Dr. Verster reported in a poster at the annual congress of the European College of Neuropsychopharmacology.

The weaving or standard deviation of lateral position was more pronounced on the return leg of the round trips.

“The problem is sustained attention. It takes one hour to perform the test. They see all sort of stuff on the side of the road, (such as) leaves falling from trees. …That is really concerning,” he added.

PARIS — Methylphenidate really can keep people with attention-deficit hyperactivity disorder on the straight and narrow, according to a study that was conducted in the Netherlands.

Dr. Joris C. Verster and his colleagues at the University of Utrecht Institute for Pharmaceutical Sciences, the Netherlands, compared the driving skills of 18 patients when they took their methylphenidate (Ritalin) with their ability when they went off medication.

Each patient made two 100-kilometer round trips in normal traffic. The protocol called for maintaining a steady speed of 95 km/hour while staying in the right lane. Twice each second, a camera on the automobile roof recorded the distance to the center of the road. The patients, aged 21–30 years, were able to maintain a steady speed on both trips, but they weaved significantly more when they were not medicated, Dr. Verster reported in a poster at the annual congress of the European College of Neuropsychopharmacology.

The weaving or standard deviation of lateral position was more pronounced on the return leg of the round trips.

“The problem is sustained attention. It takes one hour to perform the test. They see all sort of stuff on the side of the road, (such as) leaves falling from trees. …That is really concerning,” he added.

PARIS — Methylphenidate really can keep people with attention-deficit hyperactivity disorder on the straight and narrow, according to a study that was conducted in the Netherlands.

Dr. Joris C. Verster and his colleagues at the University of Utrecht Institute for Pharmaceutical Sciences, the Netherlands, compared the driving skills of 18 patients when they took their methylphenidate (Ritalin) with their ability when they went off medication.

Each patient made two 100-kilometer round trips in normal traffic. The protocol called for maintaining a steady speed of 95 km/hour while staying in the right lane. Twice each second, a camera on the automobile roof recorded the distance to the center of the road. The patients, aged 21–30 years, were able to maintain a steady speed on both trips, but they weaved significantly more when they were not medicated, Dr. Verster reported in a poster at the annual congress of the European College of Neuropsychopharmacology.

The weaving or standard deviation of lateral position was more pronounced on the return leg of the round trips.

“The problem is sustained attention. It takes one hour to perform the test. They see all sort of stuff on the side of the road, (such as) leaves falling from trees. …That is really concerning,” he added.

TUCSON, ARIZ. – A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically–and possibly clinically. People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While calling for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity.

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. – A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically–and possibly clinically. People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While calling for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity.

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.

TUCSON, ARIZ. – A psychological trait associated with heightened awareness of bodily distress may help to explain why some rheumatoid arthritis patients suffer more from achiness, malaise, and fatigue than do others with similar disease severity, Dr. Ilana M. Braun reported at the annual meeting of the Academy of Psychosomatic Medicine.

The trait, somatic absorption, was closely associated with generalized symptoms of rheumatoid arthritis in 87 patients studied by Dr. Braun, a psychiatrist at Harvard Medical School and Massachusetts General Hospital in Boston. It had no relationship to specific symptoms, such as joint pain, swelling, stiffness, and deformity, or to disease severity.

The magnitude of effect was modest, accounting for just 4% of variability in nonspecific symptoms, but Dr. Braun noted that it was significant statistically–and possibly clinically. People who score high on measures of absorption have a capacity for deep involvement in sensory events, she said. They have a heightened sense of reality that makes them more sensitive not only to bodily distress, but also to hypnosis and to biofeedback.

“There might be a role for psychiatry in the treatment of rheumatoid arthritis,” she said, questioning whether some patients might respond to these kinds of interventions for nonspecific symptoms.

“It is a personality style that you can target,” Dr. Braun added in an interview. “This is not a disorder. These are perfectly healthy people [mentally]. They just have a certain way of responding to the world.”

While calling for more research into the clinical utility of her finding, Dr. Braun suggested that ultimately it may present rheumatologists with an alternative to increasing medication when patients complain they feel poorly in the absence of specific symptoms. “What I am saying is, for the malaise and the fatigue don't double the dose,” she said. “Send them to the hypnotist.”

The study was supported by a Webb Fellowship from the academy. Dr. Braun enrolled patients from a larger, longitudinal study of rheumatoid arthritis. The largely female population had a median age of 55.5 years. A majority, 85%, had been to college, more than half were employed, and about half were married.

Patients completed the 14-item Rheumatoid Arthritis Symptoms Questionnaire. Dr. Braun and her coinvestigators also used erythrocyte sedimentation rate and a standard 28-joint physical examination by a rheumatologist to measure disease severity.

Assessment of somatic absorption was based on the 29-item Somatic Absorption Scale, a measure derived from the Tellegen Absorption Scale. Dr. Braun said the Somatic Absorption Scale focuses on “absorption as it pertains to somatic or visceral experience.” For example, a subject might be asked whether she could imagine her arm being so heavy she could not move it, or if she notices how her clothes feel against her skin.

Dr. Braun reported somatic absorption was significantly more pronounced in younger subjects, people with more severe psychiatric symptoms, African Americans, and Hispanics. Rheumatoid arthritis symptoms with statistically significant ties to somatic absorption were pain in limbs, pain in back, fatigue, generalized aching, and “feeling sick all over.”

In a discussion of the findings, Dr. Stephen J. Ferrando said he found himself looking up the literature on absorption, a personality construct developed in the 1970s to assess which patients might respond to hypnosis and biofeedback.

Dr. Ferrando, professor of clinical psychiatry and clinical public health at Cornell University in New York, called the findings very interesting and said he looks forward to an analysis of how the subjects fare in the longitudinal study from which the population was drawn.