Jane Salodof MacNeil

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 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 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.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people 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 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 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,” Dr. Dieperink said. “That was the synergism–constantly attending to the alcohol use at every visit–which we think made a big difference.”

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

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 score on the AUDIT-C 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 on average 17.3 of the 30 days 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 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 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.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people 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 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 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,” Dr. Dieperink said. “That was the synergism–constantly attending to the alcohol use at every visit–which we think made a big difference.”

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

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 score on the AUDIT-C 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 on average 17.3 of the 30 days 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 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 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.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people 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 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 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,” Dr. Dieperink said. “That was the synergism–constantly attending to the alcohol use at every visit–which we think made a big difference.”

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

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 score on the AUDIT-C 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 on average 17.3 of the 30 days 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.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview.

Conservative management, as prescribed in the study, includes not lying down after meals, avoiding certain foods, raising the head of the bed, and taking antacids. Physicians know this does not work, and prescribe drugs as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio.

“Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes and reflux symptoms in patients treated with conservative management, the drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded.

The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview.

Conservative management, as prescribed in the study, includes not lying down after meals, avoiding certain foods, raising the head of the bed, and taking antacids. Physicians know this does not work, and prescribe drugs as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio.

“Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes and reflux symptoms in patients treated with conservative management, the drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded.

The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview.

Conservative management, as prescribed in the study, includes not lying down after meals, avoiding certain foods, raising the head of the bed, and taking antacids. Physicians know this does not work, and prescribe drugs as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio.

“Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes and reflux symptoms in patients treated with conservative management, the drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded.

The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

KAPALUA, HAWAII — Paraphenylenediamine, a chemical found in permanent hair and fur dyes and temporary henna tattoos, has been chosen as the American Contact Dermatitis Society's 2006 Allergen of the Year.

“All these little kids who become allergic to their henna tattoos will not be able to dye their hair permanently again,” Dr. David E. Cohen said at the Winter Clinical Dermatology Conference, Hawaii, where he announced the selection.

Dr. Cohen, director of allergic, occupational, and environmental dermatology at New York University School of Medicine, said the dubious honor is designed to draw attention to allergens that are very common and/or underrecognized and merit more attention because they are causing significant contact dermatitis.

As the society's presentation on paraphenylenediamine has not yet been published, he gave his views on why physicians need to be more aware of its effects.

Paraphenylenediamine is well known as an allergen that can provoke reactions to permanent hair dyes, according to Dr. Cohen. The heightened sensitivity brought on by its use in temporary henna tattoos is a newer phenomenon.

Distinguishing ceremonial tattoos from the darker temporary products sold in this country, he said henna is safe as used in India and other traditional societies.

“Those [ceremonial tattoos] are pure henna tattoos, but the black henna tattoos are compounded with paraphenylenediamine to get the darker color and to get more endurance,” he explained in an interview at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc.

As a result the commercial tattoos can contain higher concentrations of paraphenylenediamine than the larger quantity used in hair dye, according to Dr. Cohen.

This exposure can in turn lead to a lifelong allergy, he said, reporting that recent research has shown that concentration of the sensitizing agent is more important than the overall dose in triggering sensitization.

“If you introduce higher concentrations of paraphenylenediamine in these small locations, you are going to increase the initial sensitization,” he said.

Practitioners have long been concerned about paraphenylenediamine, he said. And finding an alternative product is difficult when allergic patients want to color their hair, which many do.

He cited a recent British study that found 18% of men and 75% of women had dyed their hair at some point during their lives. The median age of first hair dye was 16 years, with a range of 1–80 years. One in 20 people who dyed their hair had an adverse reaction. Of these, only 15% sought help from a dermatologist (Br. J. Dermatol. 2005;153:132–5).

Typically, packages of permanent dyes include a sensitivity test that purchasers can use at home if they are concerned about an allergic reaction. Dr. Cohen recommended that people be encouraged to try these tests before using a product that contains paraphenylenediamine.

“It is almost as good as doing our patch test,” he said. “They will learn quickly if they are allergic to it.

In addition, Dr. Cohen urged physicians to be familiar with previous Allergens of the Year, of which he noted the following:

▸ 2005: Corticosteroids. Dr. Cohen said screening tests are available for tixocortol, budesonide, and hydrocortisone butyrate.

▸ 2004: Cocamidopropyl betaine. Found in more than 600 personal care products “such as shampoos, bath products, and eye and facial cleansers,” it can produce low-level irritation in the face, neck, and hands.

▸ 2003: Bacitracin. Dr. Cohen said about 9% of people who undergo patch tests and 1% of the general population are sensitive.

▸ 2002: Thimerosal. This substance was actually designated “non-Allergen of the Year,” according to Dr. Cohen. Removed from many products, it can still be found in most flu shots, he said. All told, 91% of thimerosal-allergic individuals have had “no reaction whatsoever” to flu shots, and the remaining 9% had only an injection site reaction.

▸ 2001: Gold. The second most common metal allergy in North America, gold allergy affects mostly women, said Dr. Cohen. About 10% of patients who take patch tests are allergic.

▸ 2000: Disperse Blue. One in five people tested for allergies to textile dyes were allergic to either blue or red, according to Dr. Cohen. Reactions to blue dyes were more than three times as common as to red. The acetate liners in clothing can be a problem for these people.

The ceremonial tattoos that use pure henna, such as those in India, are safe. DR. COHEN

KAPALUA, HAWAII — Paraphenylenediamine, a chemical found in permanent hair and fur dyes and temporary henna tattoos, has been chosen as the American Contact Dermatitis Society's 2006 Allergen of the Year.

“All these little kids who become allergic to their henna tattoos will not be able to dye their hair permanently again,” Dr. David E. Cohen said at the Winter Clinical Dermatology Conference, Hawaii, where he announced the selection.

Dr. Cohen, director of allergic, occupational, and environmental dermatology at New York University School of Medicine, said the dubious honor is designed to draw attention to allergens that are very common and/or underrecognized and merit more attention because they are causing significant contact dermatitis.

As the society's presentation on paraphenylenediamine has not yet been published, he gave his views on why physicians need to be more aware of its effects.

Paraphenylenediamine is well known as an allergen that can provoke reactions to permanent hair dyes, according to Dr. Cohen. The heightened sensitivity brought on by its use in temporary henna tattoos is a newer phenomenon.

Distinguishing ceremonial tattoos from the darker temporary products sold in this country, he said henna is safe as used in India and other traditional societies.

“Those [ceremonial tattoos] are pure henna tattoos, but the black henna tattoos are compounded with paraphenylenediamine to get the darker color and to get more endurance,” he explained in an interview at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc.

As a result the commercial tattoos can contain higher concentrations of paraphenylenediamine than the larger quantity used in hair dye, according to Dr. Cohen.

This exposure can in turn lead to a lifelong allergy, he said, reporting that recent research has shown that concentration of the sensitizing agent is more important than the overall dose in triggering sensitization.

“If you introduce higher concentrations of paraphenylenediamine in these small locations, you are going to increase the initial sensitization,” he said.

Practitioners have long been concerned about paraphenylenediamine, he said. And finding an alternative product is difficult when allergic patients want to color their hair, which many do.

He cited a recent British study that found 18% of men and 75% of women had dyed their hair at some point during their lives. The median age of first hair dye was 16 years, with a range of 1–80 years. One in 20 people who dyed their hair had an adverse reaction. Of these, only 15% sought help from a dermatologist (Br. J. Dermatol. 2005;153:132–5).

Typically, packages of permanent dyes include a sensitivity test that purchasers can use at home if they are concerned about an allergic reaction. Dr. Cohen recommended that people be encouraged to try these tests before using a product that contains paraphenylenediamine.

“It is almost as good as doing our patch test,” he said. “They will learn quickly if they are allergic to it.

In addition, Dr. Cohen urged physicians to be familiar with previous Allergens of the Year, of which he noted the following:

▸ 2005: Corticosteroids. Dr. Cohen said screening tests are available for tixocortol, budesonide, and hydrocortisone butyrate.

▸ 2004: Cocamidopropyl betaine. Found in more than 600 personal care products “such as shampoos, bath products, and eye and facial cleansers,” it can produce low-level irritation in the face, neck, and hands.

▸ 2003: Bacitracin. Dr. Cohen said about 9% of people who undergo patch tests and 1% of the general population are sensitive.

▸ 2002: Thimerosal. This substance was actually designated “non-Allergen of the Year,” according to Dr. Cohen. Removed from many products, it can still be found in most flu shots, he said. All told, 91% of thimerosal-allergic individuals have had “no reaction whatsoever” to flu shots, and the remaining 9% had only an injection site reaction.

▸ 2001: Gold. The second most common metal allergy in North America, gold allergy affects mostly women, said Dr. Cohen. About 10% of patients who take patch tests are allergic.

▸ 2000: Disperse Blue. One in five people tested for allergies to textile dyes were allergic to either blue or red, according to Dr. Cohen. Reactions to blue dyes were more than three times as common as to red. The acetate liners in clothing can be a problem for these people.

The ceremonial tattoos that use pure henna, such as those in India, are safe. DR. COHEN

KAPALUA, HAWAII — Paraphenylenediamine, a chemical found in permanent hair and fur dyes and temporary henna tattoos, has been chosen as the American Contact Dermatitis Society's 2006 Allergen of the Year.

“All these little kids who become allergic to their henna tattoos will not be able to dye their hair permanently again,” Dr. David E. Cohen said at the Winter Clinical Dermatology Conference, Hawaii, where he announced the selection.

Dr. Cohen, director of allergic, occupational, and environmental dermatology at New York University School of Medicine, said the dubious honor is designed to draw attention to allergens that are very common and/or underrecognized and merit more attention because they are causing significant contact dermatitis.

As the society's presentation on paraphenylenediamine has not yet been published, he gave his views on why physicians need to be more aware of its effects.

Paraphenylenediamine is well known as an allergen that can provoke reactions to permanent hair dyes, according to Dr. Cohen. The heightened sensitivity brought on by its use in temporary henna tattoos is a newer phenomenon.

Distinguishing ceremonial tattoos from the darker temporary products sold in this country, he said henna is safe as used in India and other traditional societies.

“Those [ceremonial tattoos] are pure henna tattoos, but the black henna tattoos are compounded with paraphenylenediamine to get the darker color and to get more endurance,” he explained in an interview at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc.

As a result the commercial tattoos can contain higher concentrations of paraphenylenediamine than the larger quantity used in hair dye, according to Dr. Cohen.

This exposure can in turn lead to a lifelong allergy, he said, reporting that recent research has shown that concentration of the sensitizing agent is more important than the overall dose in triggering sensitization.

“If you introduce higher concentrations of paraphenylenediamine in these small locations, you are going to increase the initial sensitization,” he said.

Practitioners have long been concerned about paraphenylenediamine, he said. And finding an alternative product is difficult when allergic patients want to color their hair, which many do.

He cited a recent British study that found 18% of men and 75% of women had dyed their hair at some point during their lives. The median age of first hair dye was 16 years, with a range of 1–80 years. One in 20 people who dyed their hair had an adverse reaction. Of these, only 15% sought help from a dermatologist (Br. J. Dermatol. 2005;153:132–5).

Typically, packages of permanent dyes include a sensitivity test that purchasers can use at home if they are concerned about an allergic reaction. Dr. Cohen recommended that people be encouraged to try these tests before using a product that contains paraphenylenediamine.

“It is almost as good as doing our patch test,” he said. “They will learn quickly if they are allergic to it.

In addition, Dr. Cohen urged physicians to be familiar with previous Allergens of the Year, of which he noted the following:

▸ 2005: Corticosteroids. Dr. Cohen said screening tests are available for tixocortol, budesonide, and hydrocortisone butyrate.

▸ 2004: Cocamidopropyl betaine. Found in more than 600 personal care products “such as shampoos, bath products, and eye and facial cleansers,” it can produce low-level irritation in the face, neck, and hands.

▸ 2003: Bacitracin. Dr. Cohen said about 9% of people who undergo patch tests and 1% of the general population are sensitive.

▸ 2002: Thimerosal. This substance was actually designated “non-Allergen of the Year,” according to Dr. Cohen. Removed from many products, it can still be found in most flu shots, he said. All told, 91% of thimerosal-allergic individuals have had “no reaction whatsoever” to flu shots, and the remaining 9% had only an injection site reaction.

▸ 2001: Gold. The second most common metal allergy in North America, gold allergy affects mostly women, said Dr. Cohen. About 10% of patients who take patch tests are allergic.

▸ 2000: Disperse Blue. One in five people tested for allergies to textile dyes were allergic to either blue or red, according to Dr. Cohen. Reactions to blue dyes were more than three times as common as to red. The acetate liners in clothing can be a problem for these people.

The ceremonial tattoos that use pure henna, such as those in India, are safe. DR. COHEN

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

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, 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, according to Dr. Lee, citing depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness.

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, noted 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.

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. No data are available on cholinesterase inhibitors, however, and 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 Dr. Lee 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. He expressed concern that widespread use will result in new issues for psychiatrists consulting on RLS 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, 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, according to Dr. Lee, citing depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness.

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, noted 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.

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. No data are available on cholinesterase inhibitors, however, and 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 Dr. Lee 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. He expressed concern that widespread use will result in new issues for psychiatrists consulting on RLS 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, 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, according to Dr. Lee, citing depressed mood, diminished interest, fatigue or loss of energy, diminished concentration, psychomotor retardation, and insomnia or excessive sleepiness.

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, noted 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.

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. No data are available on cholinesterase inhibitors, however, and 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 Dr. Lee 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. He expressed concern that widespread use will result in new issues for psychiatrists consulting on RLS patients.

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium.

“It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she said she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium.

“It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she said she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium.

“It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she said she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SANTA ANA PUEBLO, N.M. — The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act—a sense of control—should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University. Portland. “And we need to let this goal start driving how they should be cared for—whether they get assisted suicide or not.”

The findings gained new currency last month when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors cited in the political debate over the law were significant in determining who chose assisted suicide. Patients who requested lethal prescriptions were no more likely to be depressed, poor, poorly educated, from minority groups, or in worse physical condition than patients who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Many who requested assisted suicide had highly successful professional careers. Overcoming adversity early in life was another common experience.

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it.”

Compared with other patients, those with amyotrophic lateral sclerosis (ALS) in Oregon have an odds ratio above 20 for dying by assisted suicide. A sense of hopelessness was an important predictor of interest in obtaining a lethal prescription, Dr. Ganzini and her associates found in a study of 100 ALS patients.

Dr. Ganzini is now studying patients in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living,” she said. Patients feared worsening of symptoms, but at the time of their requests, none complained of physical symptoms worse than 2 on a scale of 1–5.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

In her current study, only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories: “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern was that the Death with Dignity Act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

The Oregon experience highlights “a very rarefied group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded.

SANTA ANA PUEBLO, N.M. — The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act—a sense of control—should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University. Portland. “And we need to let this goal start driving how they should be cared for—whether they get assisted suicide or not.”

The findings gained new currency last month when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors cited in the political debate over the law were significant in determining who chose assisted suicide. Patients who requested lethal prescriptions were no more likely to be depressed, poor, poorly educated, from minority groups, or in worse physical condition than patients who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Many who requested assisted suicide had highly successful professional careers. Overcoming adversity early in life was another common experience.

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it.”

Compared with other patients, those with amyotrophic lateral sclerosis (ALS) in Oregon have an odds ratio above 20 for dying by assisted suicide. A sense of hopelessness was an important predictor of interest in obtaining a lethal prescription, Dr. Ganzini and her associates found in a study of 100 ALS patients.

Dr. Ganzini is now studying patients in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living,” she said. Patients feared worsening of symptoms, but at the time of their requests, none complained of physical symptoms worse than 2 on a scale of 1–5.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

In her current study, only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories: “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern was that the Death with Dignity Act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

The Oregon experience highlights “a very rarefied group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded.

SANTA ANA PUEBLO, N.M. — The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act—a sense of control—should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University. Portland. “And we need to let this goal start driving how they should be cared for—whether they get assisted suicide or not.”

The findings gained new currency last month when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors cited in the political debate over the law were significant in determining who chose assisted suicide. Patients who requested lethal prescriptions were no more likely to be depressed, poor, poorly educated, from minority groups, or in worse physical condition than patients who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Many who requested assisted suicide had highly successful professional careers. Overcoming adversity early in life was another common experience.

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it.”

Compared with other patients, those with amyotrophic lateral sclerosis (ALS) in Oregon have an odds ratio above 20 for dying by assisted suicide. A sense of hopelessness was an important predictor of interest in obtaining a lethal prescription, Dr. Ganzini and her associates found in a study of 100 ALS patients.

Dr. Ganzini is now studying patients in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living,” she said. Patients feared worsening of symptoms, but at the time of their requests, none complained of physical symptoms worse than 2 on a scale of 1–5.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

In her current study, only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories: “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern was that the Death with Dignity Act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

The Oregon experience highlights “a very rarefied group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded.

ASPEN, COLO. — Dr. Mark J. Abzug has proposed a three-staged diagnostic approach to testing a child ill with encephalitis.

Encephalitis has an extraordinary number of possible causes for which an ever-increasing number of tests are available, he said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

Under the banner of broad differential diagnoses, he listed more than 100 viruses; more than a dozen bacteria; parasites; fungi; parameningeal focus, autoimmune conditions, metabolic disorders; toxins; drugs; malignancy; and hemorrhage.

Even with extensive investigation, the etiology is elusive, according to Dr. Abzug, a professor of pediatrics at the University of Colorado, Denver.

Studies find a cause in only 25%–65% of cases.

“Encephalitis is one of the most frustrating, if not the most frustrating, infectious disease consults,” Dr. Abzug commented.

“Here is a child who was well, usually up to a day or two before. By the time you see the child, he or she may now be neurologically devastated,” he said.

Few therapeutics are available, he added, and the damage is often irreversible in children who survive.

With so many possible causes and such poor results, Dr. Abzug offered his proposal, presented as “arguable,” as an answer to a fundamental question for clinicians: Where do you start?

A reasonable approach begins with patient history, he said. It often provides more valuable information than diagnostic tests.

Dr. Abzug urged clinicians to ask about respiratory and gastrointestinal symptoms, vaccinations, family exposures to infectious diseases, recent travel, animal and insect exposures, consumption of unpasteurized dairy products, recreational activities such as spelunking and hiking, and pica/geophagia.

Seasonal outbreaks and diseases prevalent in the community also should be considered, he said.

Physical examination is not very helpful, as the findings do not usually point to a specific etiology, according to Dr. Abzug.

Focality, in particular, is almost always—although not uniformly—present in herpes simplex infections, but also can suggest other diseases.

“All that is focal is not herpes simplex disease.”

His staged approach begins with first-line testing for the most likely causes. Dr. Abzug recommended cerebrospinal fluid (CSF) polymerase chain reaction (PCR) testing for herpes simplex virus and enterovirus.

The former accounts for 10%–20% of cases in the United States, the latter for up to 80% of encephalitis cases in which etiology is proved, he said.

Another 8%–10% of encephalitis cases with proven etiology are attributed to influenza virus.

In enterovirus season, do a viral culture or PCR of throat and rectal specimens, Dr. Abzug said.

During respiratory season, do a nasal wash with direct fluorescent antibody/viral culture testing for influenza, adenovirus, and other known respiratory viruses.

First-line testing also should include evaluation of symptomatic body sites and, if suggested clinically or by epidemiologic history, tests for exposure-related pathogens requiring specific treatments, such as tuberculosis.

In immunocompromised patients, do a CSF test for cryptococcal antigen and CSF PCR for varicella zoster, cytomegalovirus, Epstein-Barr virus, and (possibly) human herpesvirus 6. Always save CSF and serum, he said.

If this does not produce a diagnosis, Dr. Abzug proposed engaging in a second line of testing.

This would include Epstein-Barr serology; Mycoplasma pneumoniae CSF and throat PCR; testing for animal-related pathogens for which there have been relevant exposures; and tests for vector-borne pathogens, such as West Nile virus and other arborviruses, and for Lyme disease, if the epidemiology suggests possible exposures.

As a third line, Dr. Abzug recommended tests for miscellaneous pathogens if they fit the clinical context, such as parvovirus PCR and serology; human immunodeficiency virus PCR and serology; and tests for other specific exposure-related pathogens.

He also said to look for parasitic disease in the presence of a subacute course and/or eosinophilia in a child presenting with encephalitis.

“You can spend lots and lots of money, and not find anything,” Dr. Abzug said, warning that no etiology will be identified in many cases.

In response to an audience question, he said he would start acyclovir treatment early on, and would continue it until herpes is ruled out or an alternate diagnosis is reached.

“Starting acyclovir until you know [the right diagnosis] is the right thing to do because the sooner you start therapy for herpes encephalitis, the better your outcome” if it turns out to be the culprit, Dr. Abzug emphasized.

ASPEN, COLO. — Dr. Mark J. Abzug has proposed a three-staged diagnostic approach to testing a child ill with encephalitis.

Encephalitis has an extraordinary number of possible causes for which an ever-increasing number of tests are available, he said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

Under the banner of broad differential diagnoses, he listed more than 100 viruses; more than a dozen bacteria; parasites; fungi; parameningeal focus, autoimmune conditions, metabolic disorders; toxins; drugs; malignancy; and hemorrhage.

Even with extensive investigation, the etiology is elusive, according to Dr. Abzug, a professor of pediatrics at the University of Colorado, Denver.

Studies find a cause in only 25%–65% of cases.

“Encephalitis is one of the most frustrating, if not the most frustrating, infectious disease consults,” Dr. Abzug commented.

“Here is a child who was well, usually up to a day or two before. By the time you see the child, he or she may now be neurologically devastated,” he said.

Few therapeutics are available, he added, and the damage is often irreversible in children who survive.

With so many possible causes and such poor results, Dr. Abzug offered his proposal, presented as “arguable,” as an answer to a fundamental question for clinicians: Where do you start?

A reasonable approach begins with patient history, he said. It often provides more valuable information than diagnostic tests.

Dr. Abzug urged clinicians to ask about respiratory and gastrointestinal symptoms, vaccinations, family exposures to infectious diseases, recent travel, animal and insect exposures, consumption of unpasteurized dairy products, recreational activities such as spelunking and hiking, and pica/geophagia.

Seasonal outbreaks and diseases prevalent in the community also should be considered, he said.

Physical examination is not very helpful, as the findings do not usually point to a specific etiology, according to Dr. Abzug.

Focality, in particular, is almost always—although not uniformly—present in herpes simplex infections, but also can suggest other diseases.

“All that is focal is not herpes simplex disease.”

His staged approach begins with first-line testing for the most likely causes. Dr. Abzug recommended cerebrospinal fluid (CSF) polymerase chain reaction (PCR) testing for herpes simplex virus and enterovirus.

The former accounts for 10%–20% of cases in the United States, the latter for up to 80% of encephalitis cases in which etiology is proved, he said.

Another 8%–10% of encephalitis cases with proven etiology are attributed to influenza virus.

In enterovirus season, do a viral culture or PCR of throat and rectal specimens, Dr. Abzug said.

During respiratory season, do a nasal wash with direct fluorescent antibody/viral culture testing for influenza, adenovirus, and other known respiratory viruses.

First-line testing also should include evaluation of symptomatic body sites and, if suggested clinically or by epidemiologic history, tests for exposure-related pathogens requiring specific treatments, such as tuberculosis.

In immunocompromised patients, do a CSF test for cryptococcal antigen and CSF PCR for varicella zoster, cytomegalovirus, Epstein-Barr virus, and (possibly) human herpesvirus 6. Always save CSF and serum, he said.

If this does not produce a diagnosis, Dr. Abzug proposed engaging in a second line of testing.

This would include Epstein-Barr serology; Mycoplasma pneumoniae CSF and throat PCR; testing for animal-related pathogens for which there have been relevant exposures; and tests for vector-borne pathogens, such as West Nile virus and other arborviruses, and for Lyme disease, if the epidemiology suggests possible exposures.

As a third line, Dr. Abzug recommended tests for miscellaneous pathogens if they fit the clinical context, such as parvovirus PCR and serology; human immunodeficiency virus PCR and serology; and tests for other specific exposure-related pathogens.

He also said to look for parasitic disease in the presence of a subacute course and/or eosinophilia in a child presenting with encephalitis.

“You can spend lots and lots of money, and not find anything,” Dr. Abzug said, warning that no etiology will be identified in many cases.

In response to an audience question, he said he would start acyclovir treatment early on, and would continue it until herpes is ruled out or an alternate diagnosis is reached.

“Starting acyclovir until you know [the right diagnosis] is the right thing to do because the sooner you start therapy for herpes encephalitis, the better your outcome” if it turns out to be the culprit, Dr. Abzug emphasized.

ASPEN, COLO. — Dr. Mark J. Abzug has proposed a three-staged diagnostic approach to testing a child ill with encephalitis.

Encephalitis has an extraordinary number of possible causes for which an ever-increasing number of tests are available, he said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

Under the banner of broad differential diagnoses, he listed more than 100 viruses; more than a dozen bacteria; parasites; fungi; parameningeal focus, autoimmune conditions, metabolic disorders; toxins; drugs; malignancy; and hemorrhage.

Even with extensive investigation, the etiology is elusive, according to Dr. Abzug, a professor of pediatrics at the University of Colorado, Denver.

Studies find a cause in only 25%–65% of cases.

“Encephalitis is one of the most frustrating, if not the most frustrating, infectious disease consults,” Dr. Abzug commented.

“Here is a child who was well, usually up to a day or two before. By the time you see the child, he or she may now be neurologically devastated,” he said.

Few therapeutics are available, he added, and the damage is often irreversible in children who survive.

With so many possible causes and such poor results, Dr. Abzug offered his proposal, presented as “arguable,” as an answer to a fundamental question for clinicians: Where do you start?

A reasonable approach begins with patient history, he said. It often provides more valuable information than diagnostic tests.

Dr. Abzug urged clinicians to ask about respiratory and gastrointestinal symptoms, vaccinations, family exposures to infectious diseases, recent travel, animal and insect exposures, consumption of unpasteurized dairy products, recreational activities such as spelunking and hiking, and pica/geophagia.

Seasonal outbreaks and diseases prevalent in the community also should be considered, he said.

Physical examination is not very helpful, as the findings do not usually point to a specific etiology, according to Dr. Abzug.

Focality, in particular, is almost always—although not uniformly—present in herpes simplex infections, but also can suggest other diseases.

“All that is focal is not herpes simplex disease.”

His staged approach begins with first-line testing for the most likely causes. Dr. Abzug recommended cerebrospinal fluid (CSF) polymerase chain reaction (PCR) testing for herpes simplex virus and enterovirus.

The former accounts for 10%–20% of cases in the United States, the latter for up to 80% of encephalitis cases in which etiology is proved, he said.

Another 8%–10% of encephalitis cases with proven etiology are attributed to influenza virus.

In enterovirus season, do a viral culture or PCR of throat and rectal specimens, Dr. Abzug said.

During respiratory season, do a nasal wash with direct fluorescent antibody/viral culture testing for influenza, adenovirus, and other known respiratory viruses.

First-line testing also should include evaluation of symptomatic body sites and, if suggested clinically or by epidemiologic history, tests for exposure-related pathogens requiring specific treatments, such as tuberculosis.

In immunocompromised patients, do a CSF test for cryptococcal antigen and CSF PCR for varicella zoster, cytomegalovirus, Epstein-Barr virus, and (possibly) human herpesvirus 6. Always save CSF and serum, he said.

If this does not produce a diagnosis, Dr. Abzug proposed engaging in a second line of testing.

This would include Epstein-Barr serology; Mycoplasma pneumoniae CSF and throat PCR; testing for animal-related pathogens for which there have been relevant exposures; and tests for vector-borne pathogens, such as West Nile virus and other arborviruses, and for Lyme disease, if the epidemiology suggests possible exposures.

As a third line, Dr. Abzug recommended tests for miscellaneous pathogens if they fit the clinical context, such as parvovirus PCR and serology; human immunodeficiency virus PCR and serology; and tests for other specific exposure-related pathogens.

He also said to look for parasitic disease in the presence of a subacute course and/or eosinophilia in a child presenting with encephalitis.

“You can spend lots and lots of money, and not find anything,” Dr. Abzug said, warning that no etiology will be identified in many cases.

In response to an audience question, he said he would start acyclovir treatment early on, and would continue it until herpes is ruled out or an alternate diagnosis is reached.

“Starting acyclovir until you know [the right diagnosis] is the right thing to do because the sooner you start therapy for herpes encephalitis, the better your outcome” if it turns out to be the culprit, Dr. Abzug emphasized.

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Dr. Diya I. Alaedeen at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 grams, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen. “It is likely that our babies were overfed.”

“When [infants] are ill, they are not using these calories to grow,” he added in an interview.

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Dr. Diya I. Alaedeen at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 grams, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen. “It is likely that our babies were overfed.”

“When [infants] are ill, they are not using these calories to grow,” he added in an interview.

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Dr. Diya I. Alaedeen at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 grams, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen. “It is likely that our babies were overfed.”

“When [infants] are ill, they are not using these calories to grow,” he added in an interview.