Jane Salodof MacNeil

SANTA ANA PUEBLO, N.M. – People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous population-based studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described numerous overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence in the community, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Additionally, six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

He suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

Anticonvulsants do not usually worsen RLS symptoms, according to Dr. Lee. He described gabapentin and carbamazepine as “viable alternatives” for treating RLS. Valproic acid and lamotrigine also may be helpful, he said, but anecdotal reports suggest lithium can exacerbate RLS and periodic leg movements.

Benzodiazepines, particularly clonazepam, may be used as an adjunctive RLS treatment, Dr. Lee said, but he warned that antihistamines such as Benadryl are poorly tolerated in this patient population.

Dopamine agonists are increasingly an option for treatment of RLS, but he said ergot-derived dopamine agonists should be avoided. He cited the possibility of heart valve abnormalities and other side effects. Instead, he suggested a trial of dopamine agonists that are not derived from ergot such as pramipexole and ropinirole.

Dr. Lee added, however, that high doses of dopamine agonists have been linked to hallucinations, compulsive gambling, and psychiatric side effects in Parkinson's disease patients.

SANTA ANA PUEBLO, N.M. – People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous population-based studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described numerous overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence in the community, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Additionally, six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

He suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

Anticonvulsants do not usually worsen RLS symptoms, according to Dr. Lee. He described gabapentin and carbamazepine as “viable alternatives” for treating RLS. Valproic acid and lamotrigine also may be helpful, he said, but anecdotal reports suggest lithium can exacerbate RLS and periodic leg movements.

Benzodiazepines, particularly clonazepam, may be used as an adjunctive RLS treatment, Dr. Lee said, but he warned that antihistamines such as Benadryl are poorly tolerated in this patient population.

Dopamine agonists are increasingly an option for treatment of RLS, but he said ergot-derived dopamine agonists should be avoided. He cited the possibility of heart valve abnormalities and other side effects. Instead, he suggested a trial of dopamine agonists that are not derived from ergot such as pramipexole and ropinirole.

Dr. Lee added, however, that high doses of dopamine agonists have been linked to hallucinations, compulsive gambling, and psychiatric side effects in Parkinson's disease patients.

SANTA ANA PUEBLO, N.M. – People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous population-based studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described numerous overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence in the community, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Additionally, six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

He suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

Anticonvulsants do not usually worsen RLS symptoms, according to Dr. Lee. He described gabapentin and carbamazepine as “viable alternatives” for treating RLS. Valproic acid and lamotrigine also may be helpful, he said, but anecdotal reports suggest lithium can exacerbate RLS and periodic leg movements.

Benzodiazepines, particularly clonazepam, may be used as an adjunctive RLS treatment, Dr. Lee said, but he warned that antihistamines such as Benadryl are poorly tolerated in this patient population.

Dopamine agonists are increasingly an option for treatment of RLS, but he said ergot-derived dopamine agonists should be avoided. He cited the possibility of heart valve abnormalities and other side effects. Instead, he suggested a trial of dopamine agonists that are not derived from ergot such as pramipexole and ropinirole.

Dr. Lee added, however, that high doses of dopamine agonists have been linked to hallucinations, compulsive gambling, and psychiatric side effects in Parkinson's disease patients.

SANTA ANA PUEBLO, N.M. – The Patient Health Questionnaire is a simple, reliable tool that any clinician can use to screen patients for depression after traumatic brain injury, Dr. Jesse R. Fann reported at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Fann and his colleagues at the University of Washington, Seattle, validated the nine-item questionnaire in a prospective cohort study with 135 patients who were also referred for structured clinical interviews.

These patients were among 478 patients enrolled at the time of analysis in a National Institutes of Health-supported study that is using the PHQ-9 to determine the prevalence of depression in people who have suffered traumatic brain injury.

“Various studies have estimated 25%–45% get depressed in the first year. The prevalence drops after the first year, but remains significantly higher than the general population,” Dr. Fann, of the department of psychiatry and behavioral sciences, said in an interview about the poster.

Just why this population is more vulnerable to depression is not clear, Dr. Fann said. Brain lesions could be a factor, he said, but many patients also suffer from psychosocial stressors, such as unstable employment and social support or abuse of alcohol or other substances.

Dr. Fann said the standard of care at most hospitals and rehabilitation centers is not to screen traumatic brain injury patients for depression.

The investigators were especially interested in the PHQ-9 because it has been validated for other medical conditions and would be easy for nonpsychiatrists to use. “It takes 2–5 minutes,” he said. “We did this over the phone. It can be filled out by the patients themselves with paper and pencil. Or it can be done face to face in an interview format.”

The PHQ-9 asks whether patients had been bothered during the previous 2 weeks by each of nine symptoms of major depressive disorder in the DSM-IV. The multiple-choice answers range from “not at all” to “nearly every day.”

“It has validity for major depression but also helps remind nonpsychiatrists what the DSM criteria are,” Dr. Fann said.

The study found the optimal criterion for a positive screen on the PHQ-9 to be a patient reporting five or more of the nine symptoms for at least several days. The researchers specified that one of these five symptoms should be a cardinal symptom: either depressed mood or anhedonia.

When patients met the optimal criterion, the poster reported the PHQ-9 had a maximum sensitivity of 0.93, maximum specificity of 0.89, positive predictive value of 0.63, and negative predictive value of 0.99 in comparison to a Structured Clinical Interview for DSM-IV (SCID). The investigators also found correlations of 0.90 with the Hopkins Symptom Checklist Depression Subscale and 0.78 with the Hamilton Rating Scale.

Dr. Fann's group conducted the study at the Harborview Medical Center in Seattle, a level I trauma center serving the states of Washington, Idaho, Montana, and Alaska. They called participants at home to administer the PHQ-9 every month or two for a year after the patients were treated for a traumatic brain injury that was severe, moderate, or complicated mild.

SANTA ANA PUEBLO, N.M. – The Patient Health Questionnaire is a simple, reliable tool that any clinician can use to screen patients for depression after traumatic brain injury, Dr. Jesse R. Fann reported at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Fann and his colleagues at the University of Washington, Seattle, validated the nine-item questionnaire in a prospective cohort study with 135 patients who were also referred for structured clinical interviews.

These patients were among 478 patients enrolled at the time of analysis in a National Institutes of Health-supported study that is using the PHQ-9 to determine the prevalence of depression in people who have suffered traumatic brain injury.

“Various studies have estimated 25%–45% get depressed in the first year. The prevalence drops after the first year, but remains significantly higher than the general population,” Dr. Fann, of the department of psychiatry and behavioral sciences, said in an interview about the poster.

Just why this population is more vulnerable to depression is not clear, Dr. Fann said. Brain lesions could be a factor, he said, but many patients also suffer from psychosocial stressors, such as unstable employment and social support or abuse of alcohol or other substances.

Dr. Fann said the standard of care at most hospitals and rehabilitation centers is not to screen traumatic brain injury patients for depression.

The investigators were especially interested in the PHQ-9 because it has been validated for other medical conditions and would be easy for nonpsychiatrists to use. “It takes 2–5 minutes,” he said. “We did this over the phone. It can be filled out by the patients themselves with paper and pencil. Or it can be done face to face in an interview format.”

The PHQ-9 asks whether patients had been bothered during the previous 2 weeks by each of nine symptoms of major depressive disorder in the DSM-IV. The multiple-choice answers range from “not at all” to “nearly every day.”

“It has validity for major depression but also helps remind nonpsychiatrists what the DSM criteria are,” Dr. Fann said.

The study found the optimal criterion for a positive screen on the PHQ-9 to be a patient reporting five or more of the nine symptoms for at least several days. The researchers specified that one of these five symptoms should be a cardinal symptom: either depressed mood or anhedonia.

When patients met the optimal criterion, the poster reported the PHQ-9 had a maximum sensitivity of 0.93, maximum specificity of 0.89, positive predictive value of 0.63, and negative predictive value of 0.99 in comparison to a Structured Clinical Interview for DSM-IV (SCID). The investigators also found correlations of 0.90 with the Hopkins Symptom Checklist Depression Subscale and 0.78 with the Hamilton Rating Scale.

Dr. Fann's group conducted the study at the Harborview Medical Center in Seattle, a level I trauma center serving the states of Washington, Idaho, Montana, and Alaska. They called participants at home to administer the PHQ-9 every month or two for a year after the patients were treated for a traumatic brain injury that was severe, moderate, or complicated mild.

SANTA ANA PUEBLO, N.M. – The Patient Health Questionnaire is a simple, reliable tool that any clinician can use to screen patients for depression after traumatic brain injury, Dr. Jesse R. Fann reported at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Fann and his colleagues at the University of Washington, Seattle, validated the nine-item questionnaire in a prospective cohort study with 135 patients who were also referred for structured clinical interviews.

These patients were among 478 patients enrolled at the time of analysis in a National Institutes of Health-supported study that is using the PHQ-9 to determine the prevalence of depression in people who have suffered traumatic brain injury.

“Various studies have estimated 25%–45% get depressed in the first year. The prevalence drops after the first year, but remains significantly higher than the general population,” Dr. Fann, of the department of psychiatry and behavioral sciences, said in an interview about the poster.

Just why this population is more vulnerable to depression is not clear, Dr. Fann said. Brain lesions could be a factor, he said, but many patients also suffer from psychosocial stressors, such as unstable employment and social support or abuse of alcohol or other substances.

Dr. Fann said the standard of care at most hospitals and rehabilitation centers is not to screen traumatic brain injury patients for depression.

The investigators were especially interested in the PHQ-9 because it has been validated for other medical conditions and would be easy for nonpsychiatrists to use. “It takes 2–5 minutes,” he said. “We did this over the phone. It can be filled out by the patients themselves with paper and pencil. Or it can be done face to face in an interview format.”

The PHQ-9 asks whether patients had been bothered during the previous 2 weeks by each of nine symptoms of major depressive disorder in the DSM-IV. The multiple-choice answers range from “not at all” to “nearly every day.”

“It has validity for major depression but also helps remind nonpsychiatrists what the DSM criteria are,” Dr. Fann said.

The study found the optimal criterion for a positive screen on the PHQ-9 to be a patient reporting five or more of the nine symptoms for at least several days. The researchers specified that one of these five symptoms should be a cardinal symptom: either depressed mood or anhedonia.

When patients met the optimal criterion, the poster reported the PHQ-9 had a maximum sensitivity of 0.93, maximum specificity of 0.89, positive predictive value of 0.63, and negative predictive value of 0.99 in comparison to a Structured Clinical Interview for DSM-IV (SCID). The investigators also found correlations of 0.90 with the Hopkins Symptom Checklist Depression Subscale and 0.78 with the Hamilton Rating Scale.

Dr. Fann's group conducted the study at the Harborview Medical Center in Seattle, a level I trauma center serving the states of Washington, Idaho, Montana, and Alaska. They called participants at home to administer the PHQ-9 every month or two for a year after the patients were treated for a traumatic brain injury that was severe, moderate, or complicated mild.

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Noting growing concern about risks faced by professional athletes, he cited the ailments of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January. An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants while battling a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players had MRSA infections in the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

Although the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find MRSA in whirlpools and taping gel and in 35 of 84 nasal swabs from players and staff. “This study is particularly scary,” Mr. Donohue said at the meeting sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes have many risks for MRSA infections, Mr. Donohue said. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

“We don't have any more bars of soap in our clubhouse anywhere. It is all liquids and gels,” he said, adding, “we spray everything with a 10% bleach solution.”

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Noting growing concern about risks faced by professional athletes, he cited the ailments of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January. An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants while battling a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players had MRSA infections in the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

Although the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find MRSA in whirlpools and taping gel and in 35 of 84 nasal swabs from players and staff. “This study is particularly scary,” Mr. Donohue said at the meeting sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes have many risks for MRSA infections, Mr. Donohue said. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

“We don't have any more bars of soap in our clubhouse anywhere. It is all liquids and gels,” he said, adding, “we spray everything with a 10% bleach solution.”

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Noting growing concern about risks faced by professional athletes, he cited the ailments of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January. An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants while battling a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players had MRSA infections in the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

Although the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find MRSA in whirlpools and taping gel and in 35 of 84 nasal swabs from players and staff. “This study is particularly scary,” Mr. Donohue said at the meeting sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes have many risks for MRSA infections, Mr. Donohue said. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

“We don't have any more bars of soap in our clubhouse anywhere. It is all liquids and gels,” he said, adding, “we spray everything with a 10% bleach solution.”

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

PARK CITY, UTAH — The growing number of fillers approved and pending approval in the United States presents cosmetic dermatologists not just with an array of choices, but also of benefits and risks specific to those choices, according to Dr. George J. Hruza.

Extra caution is required when injecting fillers into the mid-dermis of the thin skin over the glabella, Dr. Hruza, who is medical director of the Laser and Dermatologic Surgery Center in St. Louis, warned at a clinical dermatology seminar sponsored by Medicis.

Dr. Hruza says he mostly uses CosmoDerm in the glabella but added that Restylane is sometimes necessary in patients who have had Botox treatments. He recommends injection levels of the upper dermis for CosmoDerm, and the mid-dermis for CosmoPlast and the hyaluronic acid fillers. He said Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously.

"Do not inject [Sculptra] superficially," Dr. Hruza said, warning that papules can result.

Also among the clinical pearls in his presentation were:

▸ When using Restylane, completely fill in an area before moving on. "It is difficult to come back to because you don't know what is swelling and what is Restylane," he said.

▸ Take steps to prevent last-minute cancellations when using Sculptra. Sold as a sterile, freeze-dried product, it is stable for only 72 hours after being reconstituted. Having to throw out two vials—enough to do two cheeks—is "pretty expensive" at $460 a vial, he said.

▸ One European study of Sculptra for facial lipoatrophy scheduled injections every 2 weeks. That's too close together. "You don't know what you are treating," he said. "It [Sculptra] takes time to build up."

▸ Manage patient expectations, so that they are realistic. "Sculptra provides gradual skin thickening. The number of treatment sessions depends on the depth of the effect," he said, adding that touch-up treatment may be needed. "Posttreatment massage by the patient is essential."

▸ Avoid the lips if using silicone off-label. Granulomas have occurred as late as 10 years after placement, he said. According to Dr. Hruza, European clinicians have seen a problem with ArteFill, a permanent filler under U.S. review. "I think there will be a problem down the road, so I won't be the first one to use these," he said.

▸ Be wary when patients want only the upper lip filled. "[The lips] don't look natural," he said, describing a ducklike effect. "Always do a little of both."

Sculptra should be reserved for large areas, and injected into the deep dermis or subcutaneously. DR. HRUZA

SCOTTSDALE, ARIZ. — Many women diagnosed with gynecologic disorders actually have a bladder condition that causes frequency, urgency, and lower pelvic pain, Dr. C. Lowell Parsons told physicians at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Parsons, a professor of urology and surgery at the University of California, San Diego, said the underlying etiology is a condition he calls lower urinary dysfunctional epithelium, or LUDE. The term refers to a compromised mucous barrier that fails to protect the bladder wall from irritants such as potassium in urine.

Recurrent urinary tract infections, dyspareunia, endometriosis, vaginitis, and vulvodynia as well as interstitial cystitis are among the conditions that present with symptoms of LUDE, according to Dr. Parsons.

Dr. Parsons treats new interstitial cystitis patients with a solution containing heparin or pentosan polysulfate sodium (Elmiron) and lidocaine. “If it takes away the symptoms, you know what the cause is,” he said.

His work contributed to the development of Elmiron, which the U.S. Food and Drug Administration approved in 1996 for relief of bladder pain or discomfort associated with interstitial cystitis. He disclosed that he has received research support and serves as a lecturer for Ortho-McNeil Inc.

He recommended the following intravesical therapeutic solution for patients with LUDE symptoms: 40,000 units of heparin or 100 mg of pentosan polysulfate sodium, 8 mL of 2% lidocaine, and 4 mL of sodium bicarbonate (8.4%). The bladder should be empty when the solution is used, he said.

In a trial reported earlier this year, 33 (94%) of 35 interstitial cystitis patients treated with a variation of the solution containing 2% lidocaine had 50% or greater symptom improvement. In another group of 47 patients given a variation of the solution with 1% lidocaine, 35 (74%) experienced relief of symptoms (Urology 2005;65:45–8).

Younger women may be able to go off heparin or Elmiron therapy after 3–6 months, according to Dr. Parsons. However, older patients have to stay on treatment indefinitely.

Interstitial cystitis starts early in life, Dr. Parsons said, but is not noticed until the symptoms become severe. “It begins in 15− and 16-year-old females with frequency—frequency they don't pay attention to,” he said, describing the disorder as a continuum.

“I think [potassium sensitivity] is the initiating event,” he said. “You don't have pelvic floor reaction until the patient is in her 30s and has had the disease for more than 10 years.”

“Pain from the bladder can refer anywhere from the navel to the interior thighs, front or back. You can't trust where the pain is. It can be anyplace,” he said, suggesting that some conditions actually are symptoms of LUDE. “It is all about how the lower urinary tract handles potassium,” he said, adding, “If you have a healthy, intact membrane, you won't react to potassium. If you do react, you have a problem.”

Dr. Parsons cited a study based on a potassium sensitivity test he developed for interstitial cystitis. He and his colleagues found 197 (81%) of 244 patients with pelvic pain were sensitive to potassium. He said the highest rates of positive response were 100% of patients with interstitial cystitis, 89% of patients with dyspareunia, and 86% of patients with endometriosis. Not one of 47 patients in a healthy control group was sensitive to potassium (Am. J. Obstet. Gynecol. 2002;187:1395–400).

In other studies cited by Dr. Parsons, patient responses on a Pelvic Pain and Urgency/Frequency questionnaire were predictive of potassium sensitivity in gynecologic patients. He said he no longer tests patients for potassium sensitivity, however, but initiates Elmiron instead.

SCOTTSDALE, ARIZ. — Many women diagnosed with gynecologic disorders actually have a bladder condition that causes frequency, urgency, and lower pelvic pain, Dr. C. Lowell Parsons told physicians at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Parsons, a professor of urology and surgery at the University of California, San Diego, said the underlying etiology is a condition he calls lower urinary dysfunctional epithelium, or LUDE. The term refers to a compromised mucous barrier that fails to protect the bladder wall from irritants such as potassium in urine.

Recurrent urinary tract infections, dyspareunia, endometriosis, vaginitis, and vulvodynia as well as interstitial cystitis are among the conditions that present with symptoms of LUDE, according to Dr. Parsons.

Dr. Parsons treats new interstitial cystitis patients with a solution containing heparin or pentosan polysulfate sodium (Elmiron) and lidocaine. “If it takes away the symptoms, you know what the cause is,” he said.

His work contributed to the development of Elmiron, which the U.S. Food and Drug Administration approved in 1996 for relief of bladder pain or discomfort associated with interstitial cystitis. He disclosed that he has received research support and serves as a lecturer for Ortho-McNeil Inc.

He recommended the following intravesical therapeutic solution for patients with LUDE symptoms: 40,000 units of heparin or 100 mg of pentosan polysulfate sodium, 8 mL of 2% lidocaine, and 4 mL of sodium bicarbonate (8.4%). The bladder should be empty when the solution is used, he said.

In a trial reported earlier this year, 33 (94%) of 35 interstitial cystitis patients treated with a variation of the solution containing 2% lidocaine had 50% or greater symptom improvement. In another group of 47 patients given a variation of the solution with 1% lidocaine, 35 (74%) experienced relief of symptoms (Urology 2005;65:45–8).

Younger women may be able to go off heparin or Elmiron therapy after 3–6 months, according to Dr. Parsons. However, older patients have to stay on treatment indefinitely.

Interstitial cystitis starts early in life, Dr. Parsons said, but is not noticed until the symptoms become severe. “It begins in 15− and 16-year-old females with frequency—frequency they don't pay attention to,” he said, describing the disorder as a continuum.

“I think [potassium sensitivity] is the initiating event,” he said. “You don't have pelvic floor reaction until the patient is in her 30s and has had the disease for more than 10 years.”

“Pain from the bladder can refer anywhere from the navel to the interior thighs, front or back. You can't trust where the pain is. It can be anyplace,” he said, suggesting that some conditions actually are symptoms of LUDE. “It is all about how the lower urinary tract handles potassium,” he said, adding, “If you have a healthy, intact membrane, you won't react to potassium. If you do react, you have a problem.”

Dr. Parsons cited a study based on a potassium sensitivity test he developed for interstitial cystitis. He and his colleagues found 197 (81%) of 244 patients with pelvic pain were sensitive to potassium. He said the highest rates of positive response were 100% of patients with interstitial cystitis, 89% of patients with dyspareunia, and 86% of patients with endometriosis. Not one of 47 patients in a healthy control group was sensitive to potassium (Am. J. Obstet. Gynecol. 2002;187:1395–400).

In other studies cited by Dr. Parsons, patient responses on a Pelvic Pain and Urgency/Frequency questionnaire were predictive of potassium sensitivity in gynecologic patients. He said he no longer tests patients for potassium sensitivity, however, but initiates Elmiron instead.

SCOTTSDALE, ARIZ. — Many women diagnosed with gynecologic disorders actually have a bladder condition that causes frequency, urgency, and lower pelvic pain, Dr. C. Lowell Parsons told physicians at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Parsons, a professor of urology and surgery at the University of California, San Diego, said the underlying etiology is a condition he calls lower urinary dysfunctional epithelium, or LUDE. The term refers to a compromised mucous barrier that fails to protect the bladder wall from irritants such as potassium in urine.

Recurrent urinary tract infections, dyspareunia, endometriosis, vaginitis, and vulvodynia as well as interstitial cystitis are among the conditions that present with symptoms of LUDE, according to Dr. Parsons.

Dr. Parsons treats new interstitial cystitis patients with a solution containing heparin or pentosan polysulfate sodium (Elmiron) and lidocaine. “If it takes away the symptoms, you know what the cause is,” he said.

His work contributed to the development of Elmiron, which the U.S. Food and Drug Administration approved in 1996 for relief of bladder pain or discomfort associated with interstitial cystitis. He disclosed that he has received research support and serves as a lecturer for Ortho-McNeil Inc.

He recommended the following intravesical therapeutic solution for patients with LUDE symptoms: 40,000 units of heparin or 100 mg of pentosan polysulfate sodium, 8 mL of 2% lidocaine, and 4 mL of sodium bicarbonate (8.4%). The bladder should be empty when the solution is used, he said.

In a trial reported earlier this year, 33 (94%) of 35 interstitial cystitis patients treated with a variation of the solution containing 2% lidocaine had 50% or greater symptom improvement. In another group of 47 patients given a variation of the solution with 1% lidocaine, 35 (74%) experienced relief of symptoms (Urology 2005;65:45–8).

Younger women may be able to go off heparin or Elmiron therapy after 3–6 months, according to Dr. Parsons. However, older patients have to stay on treatment indefinitely.

Interstitial cystitis starts early in life, Dr. Parsons said, but is not noticed until the symptoms become severe. “It begins in 15− and 16-year-old females with frequency—frequency they don't pay attention to,” he said, describing the disorder as a continuum.

“I think [potassium sensitivity] is the initiating event,” he said. “You don't have pelvic floor reaction until the patient is in her 30s and has had the disease for more than 10 years.”

“Pain from the bladder can refer anywhere from the navel to the interior thighs, front or back. You can't trust where the pain is. It can be anyplace,” he said, suggesting that some conditions actually are symptoms of LUDE. “It is all about how the lower urinary tract handles potassium,” he said, adding, “If you have a healthy, intact membrane, you won't react to potassium. If you do react, you have a problem.”

Dr. Parsons cited a study based on a potassium sensitivity test he developed for interstitial cystitis. He and his colleagues found 197 (81%) of 244 patients with pelvic pain were sensitive to potassium. He said the highest rates of positive response were 100% of patients with interstitial cystitis, 89% of patients with dyspareunia, and 86% of patients with endometriosis. Not one of 47 patients in a healthy control group was sensitive to potassium (Am. J. Obstet. Gynecol. 2002;187:1395–400).

In other studies cited by Dr. Parsons, patient responses on a Pelvic Pain and Urgency/Frequency questionnaire were predictive of potassium sensitivity in gynecologic patients. He said he no longer tests patients for potassium sensitivity, however, but initiates Elmiron instead.

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients who were flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some of the patients relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, said in an interview at the meeting.

“It's a cost-effective way to help people start treatment,” he added.

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you're sober,” Dr. Dieperink said. He and his colleagues reasoned that people who are facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment.

Over time, the collaboration between the two groups took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit.

Instruments used for screening included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” said Dr. Dieperink.

“That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference,” he explained.

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend that they cut back, and offer to arrange follow-up visits with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had received some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean AUDIT-C score was 6.5. In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol for an average of 17.3 days during the 30-day period before they came to the clinic, consuming a mean of 9.5 drinks per day.

After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

Of 37 patients who participated in the follow-up program with the clinical nurse-specialist and/or a mental health practitioner, only 3 were excluded from antiviral therapy because of continued alcohol use. Seventeen were offered retroviral therapy, and 13 started treatment.

The investigators said the treatment rate, 28% of patients with serious alcohol use, compared favorably with the 21% treatment rate reported for consecutive hepatitis C patients in Veterans Affairs clinics nationwide.

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients who were flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some of the patients relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, said in an interview at the meeting.

“It's a cost-effective way to help people start treatment,” he added.

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you're sober,” Dr. Dieperink said. He and his colleagues reasoned that people who are facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment.

Over time, the collaboration between the two groups took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit.

Instruments used for screening included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” said Dr. Dieperink.

“That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference,” he explained.

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend that they cut back, and offer to arrange follow-up visits with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had received some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean AUDIT-C score was 6.5. In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol for an average of 17.3 days during the 30-day period before they came to the clinic, consuming a mean of 9.5 drinks per day.

After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

Of 37 patients who participated in the follow-up program with the clinical nurse-specialist and/or a mental health practitioner, only 3 were excluded from antiviral therapy because of continued alcohol use. Seventeen were offered retroviral therapy, and 13 started treatment.

The investigators said the treatment rate, 28% of patients with serious alcohol use, compared favorably with the 21% treatment rate reported for consecutive hepatitis C patients in Veterans Affairs clinics nationwide.

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients who were flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some of the patients relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, said in an interview at the meeting.

“It's a cost-effective way to help people start treatment,” he added.

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you're sober,” Dr. Dieperink said. He and his colleagues reasoned that people who are facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment.

Over time, the collaboration between the two groups took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit.

Instruments used for screening included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” said Dr. Dieperink.

“That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference,” he explained.

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend that they cut back, and offer to arrange follow-up visits with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had received some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean AUDIT-C score was 6.5. In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol for an average of 17.3 days during the 30-day period before they came to the clinic, consuming a mean of 9.5 drinks per day.

After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

Of 37 patients who participated in the follow-up program with the clinical nurse-specialist and/or a mental health practitioner, only 3 were excluded from antiviral therapy because of continued alcohol use. Seventeen were offered retroviral therapy, and 13 started treatment.

The investigators said the treatment rate, 28% of patients with serious alcohol use, compared favorably with the 21% treatment rate reported for consecutive hepatitis C patients in Veterans Affairs clinics nationwide.

SANTA ANA PUEBLO, N.M. — People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described many overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

Dr. Lee suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, he said, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

SANTA ANA PUEBLO, N.M. — People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described many overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

Dr. Lee suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, he said, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

SANTA ANA PUEBLO, N.M. — People with restless legs syndrome were three times more likely to have a major depressive disorder in a study of 1,071 Baltimore residents reported by Dr. Hochang Benjamin Lee at the annual meeting of the Academy of Psychosomatic Medicine.

Investigators from Johns Hopkins University in Baltimore found major depressive disorder in 8 of 42 patients (19%) diagnosed with restless legs syndrome (RLS). Only 8.4% of those without RLS met the DSM-IV criteria for depression in diagnostic interviews.

“Depression and anxiety are common in RLS, and vice versa,” said Dr. Lee of the Neuropsychiatry and Memory Group at Johns Hopkins. Previous studies suggested a connection, he said, but the new study is “probably the most definitive.”

Dr. Lee described many overlaps between the two disorders, both of which are diagnosed on the basis of subjective reports from the patient. He said the two conditions have similar prevalence, occur twice as often in women as in men, present with diurnal variation, and tend to run in families. Both also have a high placebo response rate in treatment trials.

Six of the nine symptoms that the DSM-IV lists for major depressive disorder are common in RLS patients, Dr. Lee said. He cited depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness. Indeed, he suggested asking depressed patients who complain of insomnia or excessive sleepiness whether they experience “a creepy crawling feeling” in their legs.

Noting that no guidelines exist for managing depression in RLS patients, Dr. Lee recommended the following strategy:

▸ If an RLS patient presents with mild depression or dysthymia, treat the RLS first and see whether mood-related symptoms improve. If the patient continues to have depressive symptoms, treat these as well.

▸ If a severe major depressive disorder occurs along with mild RLS, treat the depression first, preferably with agents that are not SSRIs or tricyclic antidepressants.

▸ If both RLS and depression are severe, however, consider treating the conditions simultaneously, but avoid using most dopamine agonists for RLS because of the possibility of the rare side effect of psychosis.

“Careful consideration is needed for treatment of major depressive disorder in patients with restless legs syndrome,” Dr. Lee warned. He ruled out many medications, saying that SSRIs and tricyclic antidepressants should be avoided whenever possible. Both can exacerbate periodic limb movements, which occur in 80%–90% of RLS patients, according to Dr. Lee.

Dr. Lee suggested nefazodone, trazodone, and bupropion as alternatives. These agents have not been reported to exacerbate periodic limb movements, he said, and they may produce improvement. Mirtazapine is sometimes recommended for depression in RLS patients, he added, but reports are conflicting.

Regarding adjunctive treatments for RLS, he said that antipsychotic medications generally exacerbate the syndrome. While atypical antipsychotic agents are less likely to do so, he said there have been reports of risperidone, quetiapine, and olanzapine worsening RLS. Aripiprazole might be worth a trial in this movement disorder, given that it is a partial dopamine agonist.

SCOTTSDALE, ARIZ. — Monsel's paste produced less pain and worked faster than fulguration by a ball electrode in a randomized clinical trial comparing the two methods for achieving hemostasis after the loop electrosurgical excision procedure; the statistical advantages were not clinically significant, however.

“It basically comes down to either method is acceptable,” Dr. Gary H. Lipscomb said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Lipscomb, director of the division of gynecologic specialties at the University of Tennessee Health Science Center in Memphis, and his coinvestigators compared the two methods in 100 women who underwent the loop electrosurgical excision procedure (LEEP) for cervical dysplasia.

They randomized the women by computer-driven numbers placed in sealed envelopes that were opened only after each patient agreed to participate in the study. Six patients (two randomized to Monsel's paste and four to ball electrode) required additional hemostasis with an alternative method.

In 47 women treated with Monsel's paste, physicians were able to stop bleeding in 118.7 seconds on average. Fulguration with 50 watts of modulated current passing through a 5-mm ball electrode took significantly longer at 207.5 seconds for 53 women in the other cohort. Dr. Lipscomb said the time difference, being little more than a minute, did not matter clinically.

Similarly, even though women randomized to Monsel's paste had significantly less pain statistically, he said neither group experienced much pain during the procedures. The average scores on a 100-mm visual analog scale were 2.2 with Monsel's paste and 11.1 with ball electrode. In both groups, the standard anesthesia protocol for the LEEP procedure called for 1% lidocaine with 1:100,000 epinephrine.

Although blood loss was slightly higher with fulguration at 20 mL, compared with 15 mL with Monsel's paste, the difference was not statistically significant. Vaginal discharge was similar with the two techniques. Follow-up information was available for less than a quarter of the patients, but no difference was observed in the recurrence of abnormal Pap smears.

Based on these outcomes, Dr. Lipscomb said physicians could feel comfortable choosing either Monsel's paste or ball electrode. He suggested the paste might have an additional advantage, not covered in the study, because it is “dirt cheap.”

Discussant Dr. Linda Brubaker congratulated Dr. Lipscomb for “a simple and sweet study” with an impact on a decision clinicians make every day.

Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., said the trial “demonstrated the clinical utility of two common hemostatic techniques that most of us use based on training or habit.”

SCOTTSDALE, ARIZ. — Monsel's paste produced less pain and worked faster than fulguration by a ball electrode in a randomized clinical trial comparing the two methods for achieving hemostasis after the loop electrosurgical excision procedure; the statistical advantages were not clinically significant, however.

“It basically comes down to either method is acceptable,” Dr. Gary H. Lipscomb said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Lipscomb, director of the division of gynecologic specialties at the University of Tennessee Health Science Center in Memphis, and his coinvestigators compared the two methods in 100 women who underwent the loop electrosurgical excision procedure (LEEP) for cervical dysplasia.

They randomized the women by computer-driven numbers placed in sealed envelopes that were opened only after each patient agreed to participate in the study. Six patients (two randomized to Monsel's paste and four to ball electrode) required additional hemostasis with an alternative method.

In 47 women treated with Monsel's paste, physicians were able to stop bleeding in 118.7 seconds on average. Fulguration with 50 watts of modulated current passing through a 5-mm ball electrode took significantly longer at 207.5 seconds for 53 women in the other cohort. Dr. Lipscomb said the time difference, being little more than a minute, did not matter clinically.

Similarly, even though women randomized to Monsel's paste had significantly less pain statistically, he said neither group experienced much pain during the procedures. The average scores on a 100-mm visual analog scale were 2.2 with Monsel's paste and 11.1 with ball electrode. In both groups, the standard anesthesia protocol for the LEEP procedure called for 1% lidocaine with 1:100,000 epinephrine.

Although blood loss was slightly higher with fulguration at 20 mL, compared with 15 mL with Monsel's paste, the difference was not statistically significant. Vaginal discharge was similar with the two techniques. Follow-up information was available for less than a quarter of the patients, but no difference was observed in the recurrence of abnormal Pap smears.

Based on these outcomes, Dr. Lipscomb said physicians could feel comfortable choosing either Monsel's paste or ball electrode. He suggested the paste might have an additional advantage, not covered in the study, because it is “dirt cheap.”

Discussant Dr. Linda Brubaker congratulated Dr. Lipscomb for “a simple and sweet study” with an impact on a decision clinicians make every day.

Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., said the trial “demonstrated the clinical utility of two common hemostatic techniques that most of us use based on training or habit.”

SCOTTSDALE, ARIZ. — Monsel's paste produced less pain and worked faster than fulguration by a ball electrode in a randomized clinical trial comparing the two methods for achieving hemostasis after the loop electrosurgical excision procedure; the statistical advantages were not clinically significant, however.

“It basically comes down to either method is acceptable,” Dr. Gary H. Lipscomb said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Lipscomb, director of the division of gynecologic specialties at the University of Tennessee Health Science Center in Memphis, and his coinvestigators compared the two methods in 100 women who underwent the loop electrosurgical excision procedure (LEEP) for cervical dysplasia.

They randomized the women by computer-driven numbers placed in sealed envelopes that were opened only after each patient agreed to participate in the study. Six patients (two randomized to Monsel's paste and four to ball electrode) required additional hemostasis with an alternative method.

In 47 women treated with Monsel's paste, physicians were able to stop bleeding in 118.7 seconds on average. Fulguration with 50 watts of modulated current passing through a 5-mm ball electrode took significantly longer at 207.5 seconds for 53 women in the other cohort. Dr. Lipscomb said the time difference, being little more than a minute, did not matter clinically.

Similarly, even though women randomized to Monsel's paste had significantly less pain statistically, he said neither group experienced much pain during the procedures. The average scores on a 100-mm visual analog scale were 2.2 with Monsel's paste and 11.1 with ball electrode. In both groups, the standard anesthesia protocol for the LEEP procedure called for 1% lidocaine with 1:100,000 epinephrine.

Although blood loss was slightly higher with fulguration at 20 mL, compared with 15 mL with Monsel's paste, the difference was not statistically significant. Vaginal discharge was similar with the two techniques. Follow-up information was available for less than a quarter of the patients, but no difference was observed in the recurrence of abnormal Pap smears.

Based on these outcomes, Dr. Lipscomb said physicians could feel comfortable choosing either Monsel's paste or ball electrode. He suggested the paste might have an additional advantage, not covered in the study, because it is “dirt cheap.”

Discussant Dr. Linda Brubaker congratulated Dr. Lipscomb for “a simple and sweet study” with an impact on a decision clinicians make every day.

Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill., said the trial “demonstrated the clinical utility of two common hemostatic techniques that most of us use based on training or habit.”

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

Dr. Del Rosso reported that a review of the literature found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns over the use of cephalo-sporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He asserted that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalo-sporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso noted in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis.

He added that the American Academy of Family Physicians has taken a similar position.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis provided support for the production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which makes Omnicef.

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

Dr. Del Rosso reported that a review of the literature found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns over the use of cephalo-sporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He asserted that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalo-sporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso noted in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis.

He added that the American Academy of Family Physicians has taken a similar position.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis provided support for the production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which makes Omnicef.

KAPALUA, HAWAII — Oral cefdinir is safe for the treatment of skin and soft-tissue infections in people who are allergic to penicillin, Dr. James Q. Del Rosso said in a poster presentation at the Winter Clinical Dermatology Conference, Hawaii.

Dr. Del Rosso reported that a review of the literature found virtually no cross-reactivity between cefdinir (Omnicef) and penicillin, despite concerns over the use of cephalo-sporins in patients with a history of penicillin allergy.

“All cephalosporin antibiotics are not created equal,” said Dr. Del Rosso, who has a private dermatology practice in Las Vegas.

He asserted that differences in the seven-position side chain structure of selected cephalosporins make cross-reactivity with penicillin less likely in second- and third-generation cephalosporins such as cefdinir.

“A thorough review of available data indicates that the frequently cited risk of 8%–18% cross-reactivity to cephalo-sporins among penicillin-allergic patients is not accurate, is misleading, and requires revision,” Dr. Del Rosso noted in his poster.

The increased risk of allergic reactions in penicillin-allergic patients is only 0.4% for first-generation cephalosporins and “nearly nil” for certain later-generation agents, which he defined as cefdinir, cefpodoxime, and cefuroxime.

“The one we use in dermatology [cefdinir] appears to have essentially no cross-reactivity with penicillin,” he said in an interview at the conference, which was sponsored by the Center for Bio-Medical Communications Inc.

Dr. Del Rosso noted that the American Academy of Pediatrics has endorsed the use of cefdinir, cefpodoxime, and cefuroxime in penicillin-allergic children, excluding those who have had life-threatening reactions such as anaphylaxis or toxic epidermal necrolysis.

He added that the American Academy of Family Physicians has taken a similar position.

“The risk of anaphylaxis associated with cephalosporin use has been cited to range from 0.1% to 0.0001%, with no cases of fatal anaphylaxis reported in children,” according to the poster.

Medicis provided support for the production of the poster.

Dr. Del Rosso is a consultant to, and serves on the speakers' bureau of, Abbott Laboratories, which makes Omnicef.

SANTA ANA PUEBLO, N.M. — Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting.

The HADS asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.

SANTA ANA PUEBLO, N.M. — Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting.

The HADS asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.

SANTA ANA PUEBLO, N.M. — Different populations may require different screening instruments for depression, according to investigators who compared the accuracy of methods for detecting depression in 209 terminally ill cancer patients in Japan.

The patients' total score on the Hospital Anxiety and Depression Scale (HADS), the most indirect tool in the study, was the most accurate indicator, Dr. Tatsuo Akechi reported in a poster at the annual meeting of the Academy of Psychosomatic Medicine.

Direct questions such as “Are you depressed?” and “Have you lost interest or pleasure?” were the least effective, identifying fewer than half the patients who were diagnosed with depression or an adjustment disorder.

“This is a very interesting and important finding because most Japanese people are not likely to express their emotion,” Dr. Akechi of Nagoya City University, Honshu, Japan, said in an interview at the meeting.

The HADS asks indirect questions, such as whether patients feel tense or wound up, enjoy the things they used to enjoy, or can sit at ease and feel relaxed.

Dr. Akechi reported the total HADS score had a sensitivity of 80% and a specificity of 67% in the Japanese patients. The HADS depression subscale was nearly as accurate, with a sensitivity of 78% and specificity of 58%.

Though highly specific, the direct questions each had a sensitivity of only 47% when considered alone. Asking a Japanese patient both questions and considering both answers raised the sensitivity only to 68%.

“When the screening target includes both an adjustment disorder and major depression, the HADS is a more useful screening method than the single-item interviews,” the investigators concluded.