Kerri Wachter

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

ORLANDO — Low-level energy is an effective technique for enhancing wound healing, said Dr. Robert F. Jackson, who offered a few postsurgery tips at the annual meeting of the American Academy of Cosmetic Surgery.

Dr. Jackson, a practicing cosmetic surgeon in Marion, Ind., focused on the use of ultrasonic massage, electrical stimulation, and low-level laser therapy.

After liposuction, external ultrasonic massage can correct minor irregularities, decrease edema, and help prevent long-term induration, he said. The therapy also stimulates tissue and wound healing.

Dr. Jackson typically starts this therapy 1 week after surgery and treats patients twice weekly until the induration is gone. He uses a level of 2 W/cm

"If you've got induration that you haven't really treated for a long time, you can still treat it, but at that point you'll also have to mechanically stretch the tissue as you use the ultrasonic therapy," Dr. Jackson said.

"It's a very good marketing tool-my patients enjoy it," he said.

When used after cosmetic surgery procedures, electric stimulation improves blood flow, increases wound tensile strength, reduces edema, inhibits bacterial growth, and reduces pain. The primary purpose, however, is to reduce postoperative pain and edema, Dr. Jackson said. Electric stimulation immediately reduces swelling and improves wound healing. And ultimately, the technique improves the end result of the surgery.

"The Department of Health and Human Services tested all of the adjunctive therapies for pressure sores. … The only [therapy] they recommended for wound care management was the use of electric stimulation," he said.

Dr. Jackson typically starts this therapy the day after surgery and treats patients twice a week in 20-minute sessions until the wounds are satisfactorily healed. He recommends starting with an intensity of 100 pulses per second and increasing the intensity until the patient can feel the pulsation. Use this intensity for a few minutes and then increase the intensity until it just becomes uncomfortable for the patient. Then reduce the intensity gradually.

Low-level laser therapy is a relatively new modality that involves the application of low-power monochromatic and coherent light to injuries and lesions. This therapy is believed to promote blood vessel growth. Dr. Jackson uses low-level laser therapy for wound and ulcer healing. The therapy also reduces pain after surgery.

He uses a 635-nm laser for 8 minutes to enhance wound healing. For incision healing, he treats patients once or twice weekly for 3 weeks. Treatments for ulcers continue until healing is complete.

For patients on the waiting list for kidney transplants, there are few certainties other than the fact that transplant is better than dialysis and a living donor is better than a deceased one.

Kidney swapping—or paired donation—is one option that is helping more patients get transplants from living donors.

In a two-way kidney swap, patient A is incompatible with donor A—because of blood type and/or human leukocyte antigen (HLA) profile—and patient B is incompatible with donor B. However, donor A is a match for recipient B and vice versa. In a four-way surgery session, kidneys are removed from donors A and B and transplanted into their compatible recipients.

“The kidney swap is part of a broader, more comprehensive program for incompatible transplants, where people have live donors but are incompatible with them,” said Dr. Lloyd Ratner, who has performed several such procedures.

In 2001, surgeons at Johns Hopkins University in Baltimore performed the first paired kidney exchange in the United States. In 2003, a larger team at Hopkins performed the world's first three-way kidney swap. To date, 35 patients have received kidney transplants through such exchanges at Hopkins, said Robert A. Montgomery, Ph.D., who led those teams.

It's estimated that more than 6,000 people with willing live donors are still waiting for a kidney transplant because they are incompatible. Kidney swapping allows patients to circumvent the waiting list for a cadaveric kidney, thus shortening time on dialysis. People on dialysis live half as long, on average, as do those who receive transplants, said Dr. Montgomery, director of the incompatible kidney transplant program at Johns Hopkins University.

Dr. Ratner agreed. “The longer you've been on dialysis, your outcome is still worse than people who have been on it for shorter periods of time.” The director of the renal transplant program at New York-Presbyterian Hospital in New York City noted, “If you get a kidney from a deceased donor, there's a 50–50 chance that the kidney will last for 10 years or more. If you get a kidney from a live donor, there's a 50–50 chance that the kidney will last for 20 years or more. … If someone happens to have a perfectly matched brother or sister, there's a 50–50 chance that the kidney will last for over 30 years or more,” said Dr. Ratner.

For patients on the waiting list for kidney transplants, there are few certainties other than the fact that transplant is better than dialysis and a living donor is better than a deceased one.

Kidney swapping—or paired donation—is one option that is helping more patients get transplants from living donors.

In a two-way kidney swap, patient A is incompatible with donor A—because of blood type and/or human leukocyte antigen (HLA) profile—and patient B is incompatible with donor B. However, donor A is a match for recipient B and vice versa. In a four-way surgery session, kidneys are removed from donors A and B and transplanted into their compatible recipients.

“The kidney swap is part of a broader, more comprehensive program for incompatible transplants, where people have live donors but are incompatible with them,” said Dr. Lloyd Ratner, who has performed several such procedures.

In 2001, surgeons at Johns Hopkins University in Baltimore performed the first paired kidney exchange in the United States. In 2003, a larger team at Hopkins performed the world's first three-way kidney swap. To date, 35 patients have received kidney transplants through such exchanges at Hopkins, said Robert A. Montgomery, Ph.D., who led those teams.

It's estimated that more than 6,000 people with willing live donors are still waiting for a kidney transplant because they are incompatible. Kidney swapping allows patients to circumvent the waiting list for a cadaveric kidney, thus shortening time on dialysis. People on dialysis live half as long, on average, as do those who receive transplants, said Dr. Montgomery, director of the incompatible kidney transplant program at Johns Hopkins University.

Dr. Ratner agreed. “The longer you've been on dialysis, your outcome is still worse than people who have been on it for shorter periods of time.” The director of the renal transplant program at New York-Presbyterian Hospital in New York City noted, “If you get a kidney from a deceased donor, there's a 50–50 chance that the kidney will last for 10 years or more. If you get a kidney from a live donor, there's a 50–50 chance that the kidney will last for 20 years or more. … If someone happens to have a perfectly matched brother or sister, there's a 50–50 chance that the kidney will last for over 30 years or more,” said Dr. Ratner.

For patients on the waiting list for kidney transplants, there are few certainties other than the fact that transplant is better than dialysis and a living donor is better than a deceased one.

Kidney swapping—or paired donation—is one option that is helping more patients get transplants from living donors.

In a two-way kidney swap, patient A is incompatible with donor A—because of blood type and/or human leukocyte antigen (HLA) profile—and patient B is incompatible with donor B. However, donor A is a match for recipient B and vice versa. In a four-way surgery session, kidneys are removed from donors A and B and transplanted into their compatible recipients.

“The kidney swap is part of a broader, more comprehensive program for incompatible transplants, where people have live donors but are incompatible with them,” said Dr. Lloyd Ratner, who has performed several such procedures.

In 2001, surgeons at Johns Hopkins University in Baltimore performed the first paired kidney exchange in the United States. In 2003, a larger team at Hopkins performed the world's first three-way kidney swap. To date, 35 patients have received kidney transplants through such exchanges at Hopkins, said Robert A. Montgomery, Ph.D., who led those teams.

It's estimated that more than 6,000 people with willing live donors are still waiting for a kidney transplant because they are incompatible. Kidney swapping allows patients to circumvent the waiting list for a cadaveric kidney, thus shortening time on dialysis. People on dialysis live half as long, on average, as do those who receive transplants, said Dr. Montgomery, director of the incompatible kidney transplant program at Johns Hopkins University.

Dr. Ratner agreed. “The longer you've been on dialysis, your outcome is still worse than people who have been on it for shorter periods of time.” The director of the renal transplant program at New York-Presbyterian Hospital in New York City noted, “If you get a kidney from a deceased donor, there's a 50–50 chance that the kidney will last for 10 years or more. If you get a kidney from a live donor, there's a 50–50 chance that the kidney will last for 20 years or more. … If someone happens to have a perfectly matched brother or sister, there's a 50–50 chance that the kidney will last for over 30 years or more,” said Dr. Ratner.

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

About 30% of demented people continue to drive. Yet “we know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up their ability to drive when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents (even “fender benders”).

▸ Receiving citations.

Physicians do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is performed in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“How do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

It's important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

About 30% of demented people continue to drive. Yet “we know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up their ability to drive when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents (even “fender benders”).

▸ Receiving citations.

Physicians do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is performed in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“How do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

It's important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

SAN JUAN, P.R. — Not all older patients with dementia are dangerous drivers, making individual assessments of fitness to drive crucial for road safety, Dr. John C. Morris said at the annual meeting of the American Association for Geriatric Psychiatry.

About 30% of demented people continue to drive. Yet “we know that all demented drivers—at some point in the course of their dementia—will become unsafe,” said Dr. Morris, professor of neurology at Washington University, St. Louis.

Demented drivers have a twofold increased risk of crashing, compared with age-matched nondemented individuals. “In particular, they're at increased risk of fatal crashes,” Dr. Morris said.

Driving is a crucial means of transportation for many older adults—losing the ability to drive means losing autonomy. For many older adults, the issue of fairness also comes into play. They don't believe it is fair to have to give up their ability to drive when they have never had an accident.

“It's very important for older adults—if they are safe to drive—to be able to continue to do so,” Dr. Morris said. As a starting point, ask not only the patient but also family and caregivers about problematic driving behaviors whenever you evaluate an older adult. In particular, ask about the following unsafe behaviors that are typically exhibited by older adults with dementia:

▸ Failing to stay in their lane or to maintain proper distance.

▸ Driving at improper speeds (too fast or too slow).

▸ Ignoring or failing to comprehend road signs.

▸ Failing to signal, check traffic, or react to other drivers.

▸ Becoming lost.

▸ Having accidents (even “fender benders”).

▸ Receiving citations.

Physicians do a fairly good job of evaluating a patient's ability to drive safely, Dr. Morris said. According to one study, physicians are accurate roughly three-quarters of the time in determining whether a person has the ability to drive safely (J. Am. Geriatr. Soc. 2005;53:94–8).

Age alone appears to be a risk factor for unsafe driving as well. Studies indicate that periodically monitoring older patients for driving ability is important. At-risk drivers should be reevaluated about every 6 months.

Here's the approach that Dr. Morris and his colleagues at Washington University's Alzheimer's disease research center use when dealing with the issue of dementia and driving:

▸ Routinely ask the patient and family if the patient is driving and, if so, about any problems or risks.

▸ Assess any comorbid factors, such as medications and visual impairment.

▸ If the patient with dementia wishes to drive and reportedly can do so safely, require confirmation with a road test.

▸ If the patient performs safely on the road test, allow continued driving until a follow-up road test is performed in 6–12 months.

▸ If the patient is determined to be an unsafe driver following a road test, initiate driving cessation.

“How do we get an older person to stop driving?” Dr. Morris asked. Appealing to the older driver's judgment usually does not work, but it is very important to maintain the patient's dignity during this process, he said. Going over with the patient and family the reasons why he or she should stop driving is sometimes helpful. “It has more weight coming from a physician,” said Dr. Morris, who also gives his patients a written reminder—a prescription—that they may not drive.

It's important that the family work to provide an alternative means of transportation for the patient. In extreme situations, when the patient is determined to continue driving, the family may have to consider simply selling the car.

STOCKHOLM — Researchers are beginning to shed light on the pathophysiology of psoriatic arthritis, with recent findings focusing on the role of bone formation factors such as vascular endothelial growth factor and nuclear factor-kappa B ligand.

Psoriatic arthritis appears to have a different vascular and immunologic profile than rheumatoid arthritis, Dr. Christopher T. Ritchlin said at an international conference on psoriasis and psoriatic arthritis.

Spondyloarthritic tissue (including psoriatic tissue) is more vascular and has more neutrophil infiltration than normal tissue. This tissue also has infiltration of CD163-positive macrophages. “These are infrequent findings in rheumatoid arthritis,” said Dr. Ritchlin of the clinical immunology research center at the University of Rochester (N.Y.). These findings seem to correlate with swollen joint count. In addition, no cyclic citrullinated peptide was found, which is a characteristic finding in rheumatoid arthritis.

Psoriatic arthritis tissue has been shown to contain greater levels of vascular endothelial growth factor (VEGF) than does rheumatoid arthritis tissue. VEGF is particularly interesting in PsA because it is involved in the stimulation of osteoclastogenesis, thereby enhancing bone formation.

Some patients with PsA have marked osteolysis in the distal digits of the feet and hands. To understand this process, Dr. Ritchlin and his colleagues looked at tissue samples of the bone/pannus junction from patients with PsA.

“We found very large, multinucleated osteoclasts at this junction,” said Dr. Ritchlin. These osteoclasts were eroding deep pits into the bone. In addition, osteoclasts were found in greater numbers in patients with PsA than in those with RA; multinucleated osteoclasts were absent in patients with osteoarthritis.

Osteoclasts arise from CD14 monocytes. When CD14 monocytes are exposed to receptor activator of nuclear factor-kappa B ligand (RANKL)—which is expressed on synovial lining cells—and either macrophage colony stimulating factor (MCSF) or RANKL and VEGF, they differentiate into osteoclasts within a few days.

The researchers also found that RANKL is highly expressed in the synovial lining tissue of patients with PsA. In addition, staining of tissue from patients with PsA also showed that the expression of osteoprotegerin—which is an antagonist to RANKL, shutting down osteoclastogenesis—was limited to endothelial cells beneath the synovial lining.

Dr. Ritchlin and his colleagues hypothesized that osteoclast precursors move from subsynovial blood vessels toward RANKL-positive synovial lining tissue, where they convert to osteoclasts.

The researchers also hypothesized that CD14 monocytes in patients with PsA might already be committed to becoming osteoclasts. To test this, the researchers collected peripheral blood mononuclear cells from psoriatic arthritis patients and left them in culture for 2 weeks.

The cultures were then stained for osteoclasts. Stained cells with three or more nuclei were counted as osteoclasts.

The researchers found numerous osteoclasts even in the absence of exogenous RANKL or MCSF. Very few such cells were found in cultures from healthy controls.

The researchers then treated the cultures with RANKL and MCSF. The osteoclasts from PsA patients increased in size, containing 30–40 nuclei. Fewer osteoclasts were seen in cultures from healthy controls and these were smaller (with fewer nuclei).

In another recent study, Dr. Ritchlin and his collaborators analyzed peripheral blood mononuclear cells from 19 patients with PsA, 46 healthy controls, and 48 patients with rheumatoid arthritis using gene expression profiling. They found 257 genes that were underexpressed and 56 that were overexpressed in patients with PsA compared with healthy controls (Molec. Med., www.molmed.org/content/obp/10.2119_2006-00003.Gulko.pdf

In particular, genes involved with mitogen-activated protein kinase pathways, ras protein, and B-cell function were expressed at reduced levels in patients with PsA, which supports dysregulation of the immune system.

STOCKHOLM — Researchers are beginning to shed light on the pathophysiology of psoriatic arthritis, with recent findings focusing on the role of bone formation factors such as vascular endothelial growth factor and nuclear factor-kappa B ligand.

Psoriatic arthritis appears to have a different vascular and immunologic profile than rheumatoid arthritis, Dr. Christopher T. Ritchlin said at an international conference on psoriasis and psoriatic arthritis.

Spondyloarthritic tissue (including psoriatic tissue) is more vascular and has more neutrophil infiltration than normal tissue. This tissue also has infiltration of CD163-positive macrophages. “These are infrequent findings in rheumatoid arthritis,” said Dr. Ritchlin of the clinical immunology research center at the University of Rochester (N.Y.). These findings seem to correlate with swollen joint count. In addition, no cyclic citrullinated peptide was found, which is a characteristic finding in rheumatoid arthritis.

Psoriatic arthritis tissue has been shown to contain greater levels of vascular endothelial growth factor (VEGF) than does rheumatoid arthritis tissue. VEGF is particularly interesting in PsA because it is involved in the stimulation of osteoclastogenesis, thereby enhancing bone formation.

Some patients with PsA have marked osteolysis in the distal digits of the feet and hands. To understand this process, Dr. Ritchlin and his colleagues looked at tissue samples of the bone/pannus junction from patients with PsA.

“We found very large, multinucleated osteoclasts at this junction,” said Dr. Ritchlin. These osteoclasts were eroding deep pits into the bone. In addition, osteoclasts were found in greater numbers in patients with PsA than in those with RA; multinucleated osteoclasts were absent in patients with osteoarthritis.

Osteoclasts arise from CD14 monocytes. When CD14 monocytes are exposed to receptor activator of nuclear factor-kappa B ligand (RANKL)—which is expressed on synovial lining cells—and either macrophage colony stimulating factor (MCSF) or RANKL and VEGF, they differentiate into osteoclasts within a few days.

The researchers also found that RANKL is highly expressed in the synovial lining tissue of patients with PsA. In addition, staining of tissue from patients with PsA also showed that the expression of osteoprotegerin—which is an antagonist to RANKL, shutting down osteoclastogenesis—was limited to endothelial cells beneath the synovial lining.

Dr. Ritchlin and his colleagues hypothesized that osteoclast precursors move from subsynovial blood vessels toward RANKL-positive synovial lining tissue, where they convert to osteoclasts.

The researchers also hypothesized that CD14 monocytes in patients with PsA might already be committed to becoming osteoclasts. To test this, the researchers collected peripheral blood mononuclear cells from psoriatic arthritis patients and left them in culture for 2 weeks.

The cultures were then stained for osteoclasts. Stained cells with three or more nuclei were counted as osteoclasts.

The researchers found numerous osteoclasts even in the absence of exogenous RANKL or MCSF. Very few such cells were found in cultures from healthy controls.

The researchers then treated the cultures with RANKL and MCSF. The osteoclasts from PsA patients increased in size, containing 30–40 nuclei. Fewer osteoclasts were seen in cultures from healthy controls and these were smaller (with fewer nuclei).

In another recent study, Dr. Ritchlin and his collaborators analyzed peripheral blood mononuclear cells from 19 patients with PsA, 46 healthy controls, and 48 patients with rheumatoid arthritis using gene expression profiling. They found 257 genes that were underexpressed and 56 that were overexpressed in patients with PsA compared with healthy controls (Molec. Med., www.molmed.org/content/obp/10.2119_2006-00003.Gulko.pdf

In particular, genes involved with mitogen-activated protein kinase pathways, ras protein, and B-cell function were expressed at reduced levels in patients with PsA, which supports dysregulation of the immune system.

STOCKHOLM — Researchers are beginning to shed light on the pathophysiology of psoriatic arthritis, with recent findings focusing on the role of bone formation factors such as vascular endothelial growth factor and nuclear factor-kappa B ligand.

Psoriatic arthritis appears to have a different vascular and immunologic profile than rheumatoid arthritis, Dr. Christopher T. Ritchlin said at an international conference on psoriasis and psoriatic arthritis.

Spondyloarthritic tissue (including psoriatic tissue) is more vascular and has more neutrophil infiltration than normal tissue. This tissue also has infiltration of CD163-positive macrophages. “These are infrequent findings in rheumatoid arthritis,” said Dr. Ritchlin of the clinical immunology research center at the University of Rochester (N.Y.). These findings seem to correlate with swollen joint count. In addition, no cyclic citrullinated peptide was found, which is a characteristic finding in rheumatoid arthritis.

Psoriatic arthritis tissue has been shown to contain greater levels of vascular endothelial growth factor (VEGF) than does rheumatoid arthritis tissue. VEGF is particularly interesting in PsA because it is involved in the stimulation of osteoclastogenesis, thereby enhancing bone formation.

Some patients with PsA have marked osteolysis in the distal digits of the feet and hands. To understand this process, Dr. Ritchlin and his colleagues looked at tissue samples of the bone/pannus junction from patients with PsA.

“We found very large, multinucleated osteoclasts at this junction,” said Dr. Ritchlin. These osteoclasts were eroding deep pits into the bone. In addition, osteoclasts were found in greater numbers in patients with PsA than in those with RA; multinucleated osteoclasts were absent in patients with osteoarthritis.

Osteoclasts arise from CD14 monocytes. When CD14 monocytes are exposed to receptor activator of nuclear factor-kappa B ligand (RANKL)—which is expressed on synovial lining cells—and either macrophage colony stimulating factor (MCSF) or RANKL and VEGF, they differentiate into osteoclasts within a few days.

The researchers also found that RANKL is highly expressed in the synovial lining tissue of patients with PsA. In addition, staining of tissue from patients with PsA also showed that the expression of osteoprotegerin—which is an antagonist to RANKL, shutting down osteoclastogenesis—was limited to endothelial cells beneath the synovial lining.

Dr. Ritchlin and his colleagues hypothesized that osteoclast precursors move from subsynovial blood vessels toward RANKL-positive synovial lining tissue, where they convert to osteoclasts.

The researchers also hypothesized that CD14 monocytes in patients with PsA might already be committed to becoming osteoclasts. To test this, the researchers collected peripheral blood mononuclear cells from psoriatic arthritis patients and left them in culture for 2 weeks.

The cultures were then stained for osteoclasts. Stained cells with three or more nuclei were counted as osteoclasts.

The researchers found numerous osteoclasts even in the absence of exogenous RANKL or MCSF. Very few such cells were found in cultures from healthy controls.

The researchers then treated the cultures with RANKL and MCSF. The osteoclasts from PsA patients increased in size, containing 30–40 nuclei. Fewer osteoclasts were seen in cultures from healthy controls and these were smaller (with fewer nuclei).

In another recent study, Dr. Ritchlin and his collaborators analyzed peripheral blood mononuclear cells from 19 patients with PsA, 46 healthy controls, and 48 patients with rheumatoid arthritis using gene expression profiling. They found 257 genes that were underexpressed and 56 that were overexpressed in patients with PsA compared with healthy controls (Molec. Med., www.molmed.org/content/obp/10.2119_2006-00003.Gulko.pdf

In particular, genes involved with mitogen-activated protein kinase pathways, ras protein, and B-cell function were expressed at reduced levels in patients with PsA, which supports dysregulation of the immune system.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

STOCKHOLM — It may be wrong to assume that patients with psoriasis and joint pain have psoriatic arthritis, according to data presented at an international conference on psoriasis and psoriatic arthritis by Dr. Elinor Mody.

“Joint pain in patients with psoriasis does not necessarily equal psoriatic arthritis,” said Dr. Mody, a rheumatologist at Brigham and Women's Hospital in Boston.

She and her colleagues assessed 71 consecutive patients with psoriasis and musculoskeletal pain who presented to a combined dermatology/rheumatology clinic. Average patient age was 53 years and 52% of the studied patients were women. All were evaluated by both a dermatologist and a rheumatologist.

Based on the Moll and Wright criteria (Semin. Arthritis Rheum. 1973;3:55–78), 41% were diagnosed with psoriatic arthritis alone. Based on the American College of Rheumatology criteria for osteoarthritis of the hand, and knee and hip radiographs, 27% were diagnosed with osteoarthritis alone. In addition, 3% were diagnosed with gout and 14% had no specific diagnosis. Fourteen percent were diagnosed with both psoriatic arthritis and osteoarthritis.

“These findings highlight that patients with psoriasis and musculoskeletal pain can have a variety of conditions causing this pain and cannot be assumed to have psoriatic arthritis,” said Dr. Mody.

Differentiating between psoriatic arthritis and other arthropathies can be difficult but is “extremely important as psoriatic arthritis is deforming and crippling and requires aggressive early therapy,” said Dr. Mody. “Better methods are needed for screening for psoriatic arthritis in a patient with psoriasis.”

To address this need, Dr. Mody and her colleagues developed the psoriatic arthritis screening and evaluation (PASE) questionnaire intended for physicians to use to screen patients with psoriasis for evidence of psoriatic arthritis. The self-administered questionnaire includes 15 five-choice questions, separated into symptom and function subscales.

Forty-five consecutive patients (24 women) answered the questionnaire prior to systemic therapy. A rheumatologist and a dermatologist working together diagnosed 27 patients with psoriasis alone and 18 with psoriatic arthritis.

Patients with psoriatic arthritis had a median total PASE score of 53, compared with a median score of 40 for patients with psoriasis alone—a difference that was statistically significant. With a total score cutoff of 47—a score of 47 or greater indicates psoriatic arthritis—sensitivity of PASE was 83% and specificity was 70%.

“These patients need to be reevaluated periodically,” said Dr. Mody. She and here colleagues recommend repeating the PASE every 6–12 months in patients with psoriasis and joint pain.

The median function score for patients with psoriatic arthritis was 27, compared with 19 for those with psoriasis alone. The median symptom score for patients with psoriatic arthritis was 24, compared with 21 for those with psoriasis alone.

The researchers are planning to assess retest reliability of the PASE, as well as to investigate changes in PASE scores following the initiation of therapy.

WASHINGTON – The presence of constipation, poor olfaction, slow reaction time, and excessive daytime sleepiness in any combination strongly suggests the presence of preclinical Parkinson's disease, according to findings from the ongoing Honolulu-Asia Aging Study presented at the World Parkinson Congress.

Dr. G. Webster Ross of the University of Hawaii in Honolulu and his colleagues on the Honolulu-Asia Aging Study (HAAS) have been able to assess the relationship between these four factors and, not only Parkinson's disease (PD), but the presence of Lewy bodies in the brain as well.

HAAS began in 1965 as the Honolulu Heart Program, a prospective study of heart disease and stroke that followed a cohort of 8,000 Japanese-American men (all born between 1900 and 1919). The aging component of the study began in 1991 with case findings for dementia and Parkinson's disease. The researchers have continued to identify cases through examinations in 1994, 1997, 1999, 2001, and 2003. The researchers also have continued surveillance of hospital death records in order to confirm diagnoses. Preclinical determinants were assessed prior to the diagnosis of PD.

An autopsy study began in 1991. Since then, the researchers have been examining stained sections of the substantia nigra, the locus coeruleus, and the amygdala for the presence of Lewy bodies. If Lewy bodies are found in any of these three areas, the researchers then look for cortical Lewy bodies as well.

“We have been able to identify those individuals with incidental Lewy bodies–that is, those that occur in decedents without dementia or Parkinson's disease,” Dr. Ross said. “We have used this incidental Lewy body stage as an … end point in addition to Parkinson's disease, with the idea that if we find risk factors or predictors of both of these conditions that it's plausible evidence that [the risk factors] probably are truly associated with the disease or with the underlying pathophysiologic process.”

The researchers recently looked at how combinations of four factors–excessive daytime sleepiness (EDS), olfactory dysfunction, constipation, and slow reaction time–might be related to the incidence of PD. For constipation and slow reaction time, they found that the incidence of PD was 1 in 1,370 for those with neither symptom, 13 in 1,402 for those with one symptom, and 4 in 82 for those with both symptoms.

They also looked at the combination of EDS and olfactory dysfunction. The incidence of Parkinson's was 1 in 370 for those with neither symptom, 5 in 452 for those with one symptom, and 2 in 32 for those with both symptoms.

They then looked at the combination of EDS, olfactory dysfunction, and slow reaction time. The incidence of PD was 1 in 298 for those with no symptoms, 10 in 1,151 for those with one symptom, 5 in 378 for those with two symptoms, and 2 in 27 for those with all three symptoms.

Individually, all four factors have been associated with Parkinson's disease. The associations are detailed in the following paragraphs:

▸ Excessive daytime sleepiness. EDS was assessed through a questionnaire that HAAS researchers sent to cohorts in 1991. The researchers found that 23% of PD patients had EDS, compared with 8% of those who did not have PD. “The incidence of Parkinson's disease among those with excessive daytime sleepiness is about 2.5 times the incidence of individuals without excessive daytime sleepiness,” Dr. Ross said.

▸ Olfactory dysfunction. Olfactory dysfunction is common among PD patients and is known to occur early in the disease process. Olfactory dysfunction also correlates with dopamine transporter density in early Parkinson's on single photon emission CT imaging. Olfaction was assessed at the 1991 and 1994 examinations of the HAAS cohort using the University of Pennsylvania Smell Identification Test, a standardized test of odor identification ability. “As odor identification improves to the highest tertile, the incidence of Parkinson's disease declines,” said Dr. Ross. Likewise, as odor identification improved among patients with incidental Lewy bodies, the percentage with Lewy bodies in the substantia nigra or the locus coeruleus went down significantly.

▸ Constipation. Constipation occurs in an estimated 80% of PD patients and appears to be independent of age, medication use, or level of physical activity. There is a loss of dopaminergic neurons in the colon, and Lewy bodies in the myenteric plexus, in patients with PD. Constipation was assessed in the HAAS cohort with a question about bowel movement frequency at midlife (1971) and again in 1991. Dr. Ross and his colleagues found that the incidence of Parkinson's disease was highest in men who reported less than one bowel movement per day, and that the incidence declined as the number of bowel movements per day increased.

▸ Reaction time. PD patients have a prolonged reaction time, which reflects the akinesia and bradykinesia of the disease. Dr. Ross and his colleagues also have determined that there is prolonged reaction time with the presence of incidental Lewy bodies. Reaction time was assessed for the HAAS cohort using a computerized reaction time test (the 3RT).

WASHINGTON – The presence of constipation, poor olfaction, slow reaction time, and excessive daytime sleepiness in any combination strongly suggests the presence of preclinical Parkinson's disease, according to findings from the ongoing Honolulu-Asia Aging Study presented at the World Parkinson Congress.

Dr. G. Webster Ross of the University of Hawaii in Honolulu and his colleagues on the Honolulu-Asia Aging Study (HAAS) have been able to assess the relationship between these four factors and, not only Parkinson's disease (PD), but the presence of Lewy bodies in the brain as well.

HAAS began in 1965 as the Honolulu Heart Program, a prospective study of heart disease and stroke that followed a cohort of 8,000 Japanese-American men (all born between 1900 and 1919). The aging component of the study began in 1991 with case findings for dementia and Parkinson's disease. The researchers have continued to identify cases through examinations in 1994, 1997, 1999, 2001, and 2003. The researchers also have continued surveillance of hospital death records in order to confirm diagnoses. Preclinical determinants were assessed prior to the diagnosis of PD.

An autopsy study began in 1991. Since then, the researchers have been examining stained sections of the substantia nigra, the locus coeruleus, and the amygdala for the presence of Lewy bodies. If Lewy bodies are found in any of these three areas, the researchers then look for cortical Lewy bodies as well.

“We have been able to identify those individuals with incidental Lewy bodies–that is, those that occur in decedents without dementia or Parkinson's disease,” Dr. Ross said. “We have used this incidental Lewy body stage as an … end point in addition to Parkinson's disease, with the idea that if we find risk factors or predictors of both of these conditions that it's plausible evidence that [the risk factors] probably are truly associated with the disease or with the underlying pathophysiologic process.”

The researchers recently looked at how combinations of four factors–excessive daytime sleepiness (EDS), olfactory dysfunction, constipation, and slow reaction time–might be related to the incidence of PD. For constipation and slow reaction time, they found that the incidence of PD was 1 in 1,370 for those with neither symptom, 13 in 1,402 for those with one symptom, and 4 in 82 for those with both symptoms.

They also looked at the combination of EDS and olfactory dysfunction. The incidence of Parkinson's was 1 in 370 for those with neither symptom, 5 in 452 for those with one symptom, and 2 in 32 for those with both symptoms.

They then looked at the combination of EDS, olfactory dysfunction, and slow reaction time. The incidence of PD was 1 in 298 for those with no symptoms, 10 in 1,151 for those with one symptom, 5 in 378 for those with two symptoms, and 2 in 27 for those with all three symptoms.

Individually, all four factors have been associated with Parkinson's disease. The associations are detailed in the following paragraphs:

▸ Excessive daytime sleepiness. EDS was assessed through a questionnaire that HAAS researchers sent to cohorts in 1991. The researchers found that 23% of PD patients had EDS, compared with 8% of those who did not have PD. “The incidence of Parkinson's disease among those with excessive daytime sleepiness is about 2.5 times the incidence of individuals without excessive daytime sleepiness,” Dr. Ross said.

▸ Olfactory dysfunction. Olfactory dysfunction is common among PD patients and is known to occur early in the disease process. Olfactory dysfunction also correlates with dopamine transporter density in early Parkinson's on single photon emission CT imaging. Olfaction was assessed at the 1991 and 1994 examinations of the HAAS cohort using the University of Pennsylvania Smell Identification Test, a standardized test of odor identification ability. “As odor identification improves to the highest tertile, the incidence of Parkinson's disease declines,” said Dr. Ross. Likewise, as odor identification improved among patients with incidental Lewy bodies, the percentage with Lewy bodies in the substantia nigra or the locus coeruleus went down significantly.

▸ Constipation. Constipation occurs in an estimated 80% of PD patients and appears to be independent of age, medication use, or level of physical activity. There is a loss of dopaminergic neurons in the colon, and Lewy bodies in the myenteric plexus, in patients with PD. Constipation was assessed in the HAAS cohort with a question about bowel movement frequency at midlife (1971) and again in 1991. Dr. Ross and his colleagues found that the incidence of Parkinson's disease was highest in men who reported less than one bowel movement per day, and that the incidence declined as the number of bowel movements per day increased.

▸ Reaction time. PD patients have a prolonged reaction time, which reflects the akinesia and bradykinesia of the disease. Dr. Ross and his colleagues also have determined that there is prolonged reaction time with the presence of incidental Lewy bodies. Reaction time was assessed for the HAAS cohort using a computerized reaction time test (the 3RT).

WASHINGTON – The presence of constipation, poor olfaction, slow reaction time, and excessive daytime sleepiness in any combination strongly suggests the presence of preclinical Parkinson's disease, according to findings from the ongoing Honolulu-Asia Aging Study presented at the World Parkinson Congress.

Dr. G. Webster Ross of the University of Hawaii in Honolulu and his colleagues on the Honolulu-Asia Aging Study (HAAS) have been able to assess the relationship between these four factors and, not only Parkinson's disease (PD), but the presence of Lewy bodies in the brain as well.

HAAS began in 1965 as the Honolulu Heart Program, a prospective study of heart disease and stroke that followed a cohort of 8,000 Japanese-American men (all born between 1900 and 1919). The aging component of the study began in 1991 with case findings for dementia and Parkinson's disease. The researchers have continued to identify cases through examinations in 1994, 1997, 1999, 2001, and 2003. The researchers also have continued surveillance of hospital death records in order to confirm diagnoses. Preclinical determinants were assessed prior to the diagnosis of PD.

An autopsy study began in 1991. Since then, the researchers have been examining stained sections of the substantia nigra, the locus coeruleus, and the amygdala for the presence of Lewy bodies. If Lewy bodies are found in any of these three areas, the researchers then look for cortical Lewy bodies as well.

“We have been able to identify those individuals with incidental Lewy bodies–that is, those that occur in decedents without dementia or Parkinson's disease,” Dr. Ross said. “We have used this incidental Lewy body stage as an … end point in addition to Parkinson's disease, with the idea that if we find risk factors or predictors of both of these conditions that it's plausible evidence that [the risk factors] probably are truly associated with the disease or with the underlying pathophysiologic process.”

The researchers recently looked at how combinations of four factors–excessive daytime sleepiness (EDS), olfactory dysfunction, constipation, and slow reaction time–might be related to the incidence of PD. For constipation and slow reaction time, they found that the incidence of PD was 1 in 1,370 for those with neither symptom, 13 in 1,402 for those with one symptom, and 4 in 82 for those with both symptoms.

They also looked at the combination of EDS and olfactory dysfunction. The incidence of Parkinson's was 1 in 370 for those with neither symptom, 5 in 452 for those with one symptom, and 2 in 32 for those with both symptoms.

They then looked at the combination of EDS, olfactory dysfunction, and slow reaction time. The incidence of PD was 1 in 298 for those with no symptoms, 10 in 1,151 for those with one symptom, 5 in 378 for those with two symptoms, and 2 in 27 for those with all three symptoms.

Individually, all four factors have been associated with Parkinson's disease. The associations are detailed in the following paragraphs:

▸ Excessive daytime sleepiness. EDS was assessed through a questionnaire that HAAS researchers sent to cohorts in 1991. The researchers found that 23% of PD patients had EDS, compared with 8% of those who did not have PD. “The incidence of Parkinson's disease among those with excessive daytime sleepiness is about 2.5 times the incidence of individuals without excessive daytime sleepiness,” Dr. Ross said.

▸ Olfactory dysfunction. Olfactory dysfunction is common among PD patients and is known to occur early in the disease process. Olfactory dysfunction also correlates with dopamine transporter density in early Parkinson's on single photon emission CT imaging. Olfaction was assessed at the 1991 and 1994 examinations of the HAAS cohort using the University of Pennsylvania Smell Identification Test, a standardized test of odor identification ability. “As odor identification improves to the highest tertile, the incidence of Parkinson's disease declines,” said Dr. Ross. Likewise, as odor identification improved among patients with incidental Lewy bodies, the percentage with Lewy bodies in the substantia nigra or the locus coeruleus went down significantly.

▸ Constipation. Constipation occurs in an estimated 80% of PD patients and appears to be independent of age, medication use, or level of physical activity. There is a loss of dopaminergic neurons in the colon, and Lewy bodies in the myenteric plexus, in patients with PD. Constipation was assessed in the HAAS cohort with a question about bowel movement frequency at midlife (1971) and again in 1991. Dr. Ross and his colleagues found that the incidence of Parkinson's disease was highest in men who reported less than one bowel movement per day, and that the incidence declined as the number of bowel movements per day increased.

▸ Reaction time. PD patients have a prolonged reaction time, which reflects the akinesia and bradykinesia of the disease. Dr. Ross and his colleagues also have determined that there is prolonged reaction time with the presence of incidental Lewy bodies. Reaction time was assessed for the HAAS cohort using a computerized reaction time test (the 3RT).

SAN JUAN, P.R. – Treating the manifestations of sleep disorders requires a broad understanding of patients' circumstances, Donald Bliwise, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

For example, both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) become more prevalent as patients age, said Dr. Bliwise, professor of neurology at Emory University in Atlanta. “RLS is really a symptom,” he said. PLMD is a polysomnographic finding, and the two often overlap. However, neither is necessary nor sufficient to make the diagnosis of the other. In order for RLS to be diagnosed, communication between the patient and the physician is critical. A diagnosis of PLMD often must be preceded by a report from the patient's bed partner of excessive movement.

RLS is characterized by uncomfortable leg sensations. These sensations are worse in the evening and at night, and worse with inactivity. Leg movement relieves the discomfort. “If someone has constant pain and discomfort, it's probably less likely to be RLS,” said Dr. Bliwise, director of the program in sleep, aging, and chronobiology at Emory. RLS is associated more with motor hyperactivity.

PLMD is characterized by stereotypic, repetitive movements of the legs–and less often the arms–during sleep or inactivity; these movements are detected by EEG in the sleep laboratory. Movements occur every 20–40 seconds and usually occur in groups of four. These movements may be associated with arousals from sleep. Sometimes the movements occur in only one limb or may switch back and forth between limbs.

Dr. Bliwise also said RLS and PLMD are very dependent on ferritin levels. “So one of the first things we do, especially with our geriatric patients, is check ferritin-iron levels,” Dr. Bliwise said. If the patient has low levels, he or she is put on iron supplementation.

RLS and PLMD are also associated with chronic renal failure, neuropathies, myelopathies, radiculopathies, pregnancy, and folate and vitamin B₁₂ deficiencies. Some medications can worsen RLS and PLMD; in particular, tricyclic antidepressants and selective serotonin reuptake inhibitors can aggravate these two conditions. Dopamine agonists are often used off label for these two conditions. Ropinirole (Requip) is indicated for the treatment of RLS.

Sleep disorders are also common in synucleinopathies and Alzheimer's disease but have different clinical presentations. “With these two broad classes of neurodegenerative conditions, you really have two kinds of clinical pictures as far as sleep disturbance is concerned,” Dr. Bliwise said.

Parkinson's disease (PD) and PD-like conditions (synucleinopathies) are often characterized by the suspension of normal REM atonia. “Often with these patients, you get a history of combativeness,” Dr. Bliwise said. They awaken from sleep often with confusion and may believe that they are being attacked, which leads to combative behavior. These patients are also sleepy during the day. These signs may even predate PD-like conditions by as much as 20 years. In terms of treating both Parkinson's disease and PD-like conditions, clonazepam, dopamine agonists, and even melatonin have been used off label with some success.

In contrast, “in Alzheimer's disease, what we typically see is agitation in the late afternoon or early evening hours–the so-called sundown syndrome,” Dr. Bliwise said. Studies have shown that this phenomenon is associated with changes in circadian rhythms. Other studies have shown that there is a profound loss of cells in the suprachiasmatic nucleus in patients with Alzheimer's disease.

Keep in mind that cholinesterase inhibitors used in treating Alzheimer's are associated with disturbed sleep. Studies suggest that these drugs may increase both REM sleep and insomnia. Atypical antipsychotics, which are sometimes used off label to treat Alzheimer's disease, are associated with somnolence. “Basically, the adverse effect of somnolence is what we're banking on when we try to use these [atypical antipsychotics] to try to treat disturbed sleep in these patients,” Dr. Bliwise said.

Finally, it is important not to overlook nocturia in patients with disordered sleep, Dr. Bliwise said. In fact, a direct association exists between the number of times a person wakes during the night to urinate, the person's age, and complaints of sleep. “It's amazing how often this is overlooked as a cause of disordered sleep,” Dr. Bliwise said. Nocturia has been associated with sleep apnea, another factor in disordered sleep.

SAN JUAN, P.R. – Treating the manifestations of sleep disorders requires a broad understanding of patients' circumstances, Donald Bliwise, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

For example, both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) become more prevalent as patients age, said Dr. Bliwise, professor of neurology at Emory University in Atlanta. “RLS is really a symptom,” he said. PLMD is a polysomnographic finding, and the two often overlap. However, neither is necessary nor sufficient to make the diagnosis of the other. In order for RLS to be diagnosed, communication between the patient and the physician is critical. A diagnosis of PLMD often must be preceded by a report from the patient's bed partner of excessive movement.

RLS is characterized by uncomfortable leg sensations. These sensations are worse in the evening and at night, and worse with inactivity. Leg movement relieves the discomfort. “If someone has constant pain and discomfort, it's probably less likely to be RLS,” said Dr. Bliwise, director of the program in sleep, aging, and chronobiology at Emory. RLS is associated more with motor hyperactivity.

PLMD is characterized by stereotypic, repetitive movements of the legs–and less often the arms–during sleep or inactivity; these movements are detected by EEG in the sleep laboratory. Movements occur every 20–40 seconds and usually occur in groups of four. These movements may be associated with arousals from sleep. Sometimes the movements occur in only one limb or may switch back and forth between limbs.

Dr. Bliwise also said RLS and PLMD are very dependent on ferritin levels. “So one of the first things we do, especially with our geriatric patients, is check ferritin-iron levels,” Dr. Bliwise said. If the patient has low levels, he or she is put on iron supplementation.

RLS and PLMD are also associated with chronic renal failure, neuropathies, myelopathies, radiculopathies, pregnancy, and folate and vitamin B₁₂ deficiencies. Some medications can worsen RLS and PLMD; in particular, tricyclic antidepressants and selective serotonin reuptake inhibitors can aggravate these two conditions. Dopamine agonists are often used off label for these two conditions. Ropinirole (Requip) is indicated for the treatment of RLS.

Sleep disorders are also common in synucleinopathies and Alzheimer's disease but have different clinical presentations. “With these two broad classes of neurodegenerative conditions, you really have two kinds of clinical pictures as far as sleep disturbance is concerned,” Dr. Bliwise said.

Parkinson's disease (PD) and PD-like conditions (synucleinopathies) are often characterized by the suspension of normal REM atonia. “Often with these patients, you get a history of combativeness,” Dr. Bliwise said. They awaken from sleep often with confusion and may believe that they are being attacked, which leads to combative behavior. These patients are also sleepy during the day. These signs may even predate PD-like conditions by as much as 20 years. In terms of treating both Parkinson's disease and PD-like conditions, clonazepam, dopamine agonists, and even melatonin have been used off label with some success.

In contrast, “in Alzheimer's disease, what we typically see is agitation in the late afternoon or early evening hours–the so-called sundown syndrome,” Dr. Bliwise said. Studies have shown that this phenomenon is associated with changes in circadian rhythms. Other studies have shown that there is a profound loss of cells in the suprachiasmatic nucleus in patients with Alzheimer's disease.

Keep in mind that cholinesterase inhibitors used in treating Alzheimer's are associated with disturbed sleep. Studies suggest that these drugs may increase both REM sleep and insomnia. Atypical antipsychotics, which are sometimes used off label to treat Alzheimer's disease, are associated with somnolence. “Basically, the adverse effect of somnolence is what we're banking on when we try to use these [atypical antipsychotics] to try to treat disturbed sleep in these patients,” Dr. Bliwise said.

Finally, it is important not to overlook nocturia in patients with disordered sleep, Dr. Bliwise said. In fact, a direct association exists between the number of times a person wakes during the night to urinate, the person's age, and complaints of sleep. “It's amazing how often this is overlooked as a cause of disordered sleep,” Dr. Bliwise said. Nocturia has been associated with sleep apnea, another factor in disordered sleep.

SAN JUAN, P.R. – Treating the manifestations of sleep disorders requires a broad understanding of patients' circumstances, Donald Bliwise, Ph.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

For example, both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) become more prevalent as patients age, said Dr. Bliwise, professor of neurology at Emory University in Atlanta. “RLS is really a symptom,” he said. PLMD is a polysomnographic finding, and the two often overlap. However, neither is necessary nor sufficient to make the diagnosis of the other. In order for RLS to be diagnosed, communication between the patient and the physician is critical. A diagnosis of PLMD often must be preceded by a report from the patient's bed partner of excessive movement.

RLS is characterized by uncomfortable leg sensations. These sensations are worse in the evening and at night, and worse with inactivity. Leg movement relieves the discomfort. “If someone has constant pain and discomfort, it's probably less likely to be RLS,” said Dr. Bliwise, director of the program in sleep, aging, and chronobiology at Emory. RLS is associated more with motor hyperactivity.

PLMD is characterized by stereotypic, repetitive movements of the legs–and less often the arms–during sleep or inactivity; these movements are detected by EEG in the sleep laboratory. Movements occur every 20–40 seconds and usually occur in groups of four. These movements may be associated with arousals from sleep. Sometimes the movements occur in only one limb or may switch back and forth between limbs.

Dr. Bliwise also said RLS and PLMD are very dependent on ferritin levels. “So one of the first things we do, especially with our geriatric patients, is check ferritin-iron levels,” Dr. Bliwise said. If the patient has low levels, he or she is put on iron supplementation.

RLS and PLMD are also associated with chronic renal failure, neuropathies, myelopathies, radiculopathies, pregnancy, and folate and vitamin B₁₂ deficiencies. Some medications can worsen RLS and PLMD; in particular, tricyclic antidepressants and selective serotonin reuptake inhibitors can aggravate these two conditions. Dopamine agonists are often used off label for these two conditions. Ropinirole (Requip) is indicated for the treatment of RLS.

Sleep disorders are also common in synucleinopathies and Alzheimer's disease but have different clinical presentations. “With these two broad classes of neurodegenerative conditions, you really have two kinds of clinical pictures as far as sleep disturbance is concerned,” Dr. Bliwise said.

Parkinson's disease (PD) and PD-like conditions (synucleinopathies) are often characterized by the suspension of normal REM atonia. “Often with these patients, you get a history of combativeness,” Dr. Bliwise said. They awaken from sleep often with confusion and may believe that they are being attacked, which leads to combative behavior. These patients are also sleepy during the day. These signs may even predate PD-like conditions by as much as 20 years. In terms of treating both Parkinson's disease and PD-like conditions, clonazepam, dopamine agonists, and even melatonin have been used off label with some success.

In contrast, “in Alzheimer's disease, what we typically see is agitation in the late afternoon or early evening hours–the so-called sundown syndrome,” Dr. Bliwise said. Studies have shown that this phenomenon is associated with changes in circadian rhythms. Other studies have shown that there is a profound loss of cells in the suprachiasmatic nucleus in patients with Alzheimer's disease.

Keep in mind that cholinesterase inhibitors used in treating Alzheimer's are associated with disturbed sleep. Studies suggest that these drugs may increase both REM sleep and insomnia. Atypical antipsychotics, which are sometimes used off label to treat Alzheimer's disease, are associated with somnolence. “Basically, the adverse effect of somnolence is what we're banking on when we try to use these [atypical antipsychotics] to try to treat disturbed sleep in these patients,” Dr. Bliwise said.

Finally, it is important not to overlook nocturia in patients with disordered sleep, Dr. Bliwise said. In fact, a direct association exists between the number of times a person wakes during the night to urinate, the person's age, and complaints of sleep. “It's amazing how often this is overlooked as a cause of disordered sleep,” Dr. Bliwise said. Nocturia has been associated with sleep apnea, another factor in disordered sleep.

The World Health Organization has launched a major initiative to standardize the way that information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, WHO is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the WHO, said in a written statement.

WHO's International Clinical Trials Registry Platform is not itself a registry but provides standards for all clinical trial registries. These standards require information about: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a WHO statement.

The WHO Registry Platform is expected to launch a Web-based search portal later this year that would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

For more information on the registry platform, visit www.who.int/ictrp/en

The World Health Organization has launched a major initiative to standardize the way that information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, WHO is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the WHO, said in a written statement.

WHO's International Clinical Trials Registry Platform is not itself a registry but provides standards for all clinical trial registries. These standards require information about: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a WHO statement.

The WHO Registry Platform is expected to launch a Web-based search portal later this year that would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

For more information on the registry platform, visit www.who.int/ictrp/en

The World Health Organization has launched a major initiative to standardize the way that information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, WHO is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the WHO, said in a written statement.

WHO's International Clinical Trials Registry Platform is not itself a registry but provides standards for all clinical trial registries. These standards require information about: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a WHO statement.

The WHO Registry Platform is expected to launch a Web-based search portal later this year that would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

For more information on the registry platform, visit www.who.int/ictrp/en

WASHINGTON — Better communication is the key to better asthma management, said an expert in pediatric asthma, who offered a few tips on improving communication with patients and parents at a meeting sponsored by the American Academy of Pediatrics.

The bottom line is that it is the family who manages a child's asthma on a daily basis. “You're not going to go home and manage your patient's asthma. It's really the family that's going to do a lot of the management,” said Dr. Michael Cabana, director of general pediatrics at the University of California, San Francisco and UCSF Children's Hospital.

However, the best management plan won't work if the family doesn't adhere to the regimen, and adherence is closely linked to clinician communication and patient education, he said.

Research indicates that there are no good predictors of family/patient adherence to asthma management plans. “It's hard to predict which parents are going to be adherent to any specific recommendation,” said Dr. Cabana.

Study results have consistently shown that less than 50% of patients adhere to daily medication regimens. In light of the difficulty in predicting which half of patients will adhere to their asthma regimens, all patients should be educated to ensure compliance, said Dr. Cabana. Communicating well and providing education are as important as prescribing the right medication.

Dr. Cabana and his colleagues recently published the results of a nationwide, randomized controlled trial that demonstrated that patients whose physicians participated in a program to enhance their communication skills had better asthma outcomes after 1 year (Pediatrics 2006;117:2149–57).

According to one model, a patient's (or parent's) beliefs influence willingness to follow preventive or therapeutic recommendations. Families have to believe that their children are susceptible to asthma, that asthma is a serious health threat to their children, that the benefits of the asthma management plan outweigh the costs, and that they can carry out the components of the asthma plan confidently.

In terms of susceptibility, some families may resist the diagnosis of asthma, believing instead that the disease is feigned. Resisting the diagnosis reduces the likelihood that the family will follow the treatment plan.

With respect to the perceived seriousness of the disease, if the family thinks asthma is not serious, they are less likely to follow the treatment plan. On the other hand, if the family overestimates the seriousness of the asthma, they may follow the plan but also may prevent the child from taking part in normal physical activities.

Although the benefits of therapy are clear to physicians, these benefits may be unclear to patients or irrelevant to their personal goals. However, the perceived costs of therapy are often obvious to families: Therapy represents a possible financial burden and harm to the child from medications; also, therapy is time consuming and difficult to carry out.

Fears about asthma medications among families are not trivial. Roughly 40% believe that these medications are addictive; 36% believe these medications are not safe for long-term use; and almost 60% believe that regular use will reduce effectiveness, said Dr. Cabana. In addition, many families lack confidence that they can manage an asthma attack at home.

But there is help. It comes in the form of specific communication techniques that are repeated and consistently used and that have been shown to enhance physician communication with patients as well as outcomes for patients:

▸ Nonverbal attentiveness, addressing immediate concerns, and giving reassuring messages all serve to relax and reassure patients so that they pay attention to what is being said.

▸ Interactive conversations and eliciting underlying fears help to improve the exchange of ideas and feelings and to gather information needed for diagnosis and treatment decisions.

▸ Tailoring messages, planning for decision making, and goal setting prepare patients to carry out the treatment at home.

▸ Nonverbal encouragement and verbal praise help build the self-confidence necessary to carry out the plan.

There also are several basic asthma concepts that must be understood by patients, if they are to use therapies successfully and control asthma triggers.

“I try to limit it to two or three key messages per visit,” said Dr. Cabana, adding that he distributes and reinforces the messages over time through discussions and handouts.

The topics include:

▸ What happens during an asthma attack.

▸ How medicines work.

▸ How to take the medicines.

▸ How to respond to changes in asthma severity.

▸ Medication safety.

▸ Goals of therapy.

▸ Criteria for successful treatment.

▸ Managing asthma at school.

▸ Identifying and avoiding triggers.

▸ Referral for further education.

Many patients and families have questions about steroids because this topic comes up frequently in the media. The key is to ask what the specific concerns are. It may be necessary to point out the differences between anabolic steroids and anti-inflammatory corticosteroids or address growth concerns.

WASHINGTON — Better communication is the key to better asthma management, said an expert in pediatric asthma, who offered a few tips on improving communication with patients and parents at a meeting sponsored by the American Academy of Pediatrics.

The bottom line is that it is the family who manages a child's asthma on a daily basis. “You're not going to go home and manage your patient's asthma. It's really the family that's going to do a lot of the management,” said Dr. Michael Cabana, director of general pediatrics at the University of California, San Francisco and UCSF Children's Hospital.

However, the best management plan won't work if the family doesn't adhere to the regimen, and adherence is closely linked to clinician communication and patient education, he said.

Research indicates that there are no good predictors of family/patient adherence to asthma management plans. “It's hard to predict which parents are going to be adherent to any specific recommendation,” said Dr. Cabana.

Study results have consistently shown that less than 50% of patients adhere to daily medication regimens. In light of the difficulty in predicting which half of patients will adhere to their asthma regimens, all patients should be educated to ensure compliance, said Dr. Cabana. Communicating well and providing education are as important as prescribing the right medication.

Dr. Cabana and his colleagues recently published the results of a nationwide, randomized controlled trial that demonstrated that patients whose physicians participated in a program to enhance their communication skills had better asthma outcomes after 1 year (Pediatrics 2006;117:2149–57).

According to one model, a patient's (or parent's) beliefs influence willingness to follow preventive or therapeutic recommendations. Families have to believe that their children are susceptible to asthma, that asthma is a serious health threat to their children, that the benefits of the asthma management plan outweigh the costs, and that they can carry out the components of the asthma plan confidently.

In terms of susceptibility, some families may resist the diagnosis of asthma, believing instead that the disease is feigned. Resisting the diagnosis reduces the likelihood that the family will follow the treatment plan.

With respect to the perceived seriousness of the disease, if the family thinks asthma is not serious, they are less likely to follow the treatment plan. On the other hand, if the family overestimates the seriousness of the asthma, they may follow the plan but also may prevent the child from taking part in normal physical activities.

Although the benefits of therapy are clear to physicians, these benefits may be unclear to patients or irrelevant to their personal goals. However, the perceived costs of therapy are often obvious to families: Therapy represents a possible financial burden and harm to the child from medications; also, therapy is time consuming and difficult to carry out.

Fears about asthma medications among families are not trivial. Roughly 40% believe that these medications are addictive; 36% believe these medications are not safe for long-term use; and almost 60% believe that regular use will reduce effectiveness, said Dr. Cabana. In addition, many families lack confidence that they can manage an asthma attack at home.

But there is help. It comes in the form of specific communication techniques that are repeated and consistently used and that have been shown to enhance physician communication with patients as well as outcomes for patients:

▸ Nonverbal attentiveness, addressing immediate concerns, and giving reassuring messages all serve to relax and reassure patients so that they pay attention to what is being said.

▸ Interactive conversations and eliciting underlying fears help to improve the exchange of ideas and feelings and to gather information needed for diagnosis and treatment decisions.

▸ Tailoring messages, planning for decision making, and goal setting prepare patients to carry out the treatment at home.

▸ Nonverbal encouragement and verbal praise help build the self-confidence necessary to carry out the plan.

There also are several basic asthma concepts that must be understood by patients, if they are to use therapies successfully and control asthma triggers.

“I try to limit it to two or three key messages per visit,” said Dr. Cabana, adding that he distributes and reinforces the messages over time through discussions and handouts.

The topics include:

▸ What happens during an asthma attack.

▸ How medicines work.

▸ How to take the medicines.

▸ How to respond to changes in asthma severity.

▸ Medication safety.

▸ Goals of therapy.

▸ Criteria for successful treatment.

▸ Managing asthma at school.

▸ Identifying and avoiding triggers.

▸ Referral for further education.

Many patients and families have questions about steroids because this topic comes up frequently in the media. The key is to ask what the specific concerns are. It may be necessary to point out the differences between anabolic steroids and anti-inflammatory corticosteroids or address growth concerns.

WASHINGTON — Better communication is the key to better asthma management, said an expert in pediatric asthma, who offered a few tips on improving communication with patients and parents at a meeting sponsored by the American Academy of Pediatrics.

The bottom line is that it is the family who manages a child's asthma on a daily basis. “You're not going to go home and manage your patient's asthma. It's really the family that's going to do a lot of the management,” said Dr. Michael Cabana, director of general pediatrics at the University of California, San Francisco and UCSF Children's Hospital.

However, the best management plan won't work if the family doesn't adhere to the regimen, and adherence is closely linked to clinician communication and patient education, he said.

Research indicates that there are no good predictors of family/patient adherence to asthma management plans. “It's hard to predict which parents are going to be adherent to any specific recommendation,” said Dr. Cabana.

Study results have consistently shown that less than 50% of patients adhere to daily medication regimens. In light of the difficulty in predicting which half of patients will adhere to their asthma regimens, all patients should be educated to ensure compliance, said Dr. Cabana. Communicating well and providing education are as important as prescribing the right medication.

Dr. Cabana and his colleagues recently published the results of a nationwide, randomized controlled trial that demonstrated that patients whose physicians participated in a program to enhance their communication skills had better asthma outcomes after 1 year (Pediatrics 2006;117:2149–57).

According to one model, a patient's (or parent's) beliefs influence willingness to follow preventive or therapeutic recommendations. Families have to believe that their children are susceptible to asthma, that asthma is a serious health threat to their children, that the benefits of the asthma management plan outweigh the costs, and that they can carry out the components of the asthma plan confidently.

In terms of susceptibility, some families may resist the diagnosis of asthma, believing instead that the disease is feigned. Resisting the diagnosis reduces the likelihood that the family will follow the treatment plan.

With respect to the perceived seriousness of the disease, if the family thinks asthma is not serious, they are less likely to follow the treatment plan. On the other hand, if the family overestimates the seriousness of the asthma, they may follow the plan but also may prevent the child from taking part in normal physical activities.

Although the benefits of therapy are clear to physicians, these benefits may be unclear to patients or irrelevant to their personal goals. However, the perceived costs of therapy are often obvious to families: Therapy represents a possible financial burden and harm to the child from medications; also, therapy is time consuming and difficult to carry out.

Fears about asthma medications among families are not trivial. Roughly 40% believe that these medications are addictive; 36% believe these medications are not safe for long-term use; and almost 60% believe that regular use will reduce effectiveness, said Dr. Cabana. In addition, many families lack confidence that they can manage an asthma attack at home.

But there is help. It comes in the form of specific communication techniques that are repeated and consistently used and that have been shown to enhance physician communication with patients as well as outcomes for patients:

▸ Nonverbal attentiveness, addressing immediate concerns, and giving reassuring messages all serve to relax and reassure patients so that they pay attention to what is being said.

▸ Interactive conversations and eliciting underlying fears help to improve the exchange of ideas and feelings and to gather information needed for diagnosis and treatment decisions.

▸ Tailoring messages, planning for decision making, and goal setting prepare patients to carry out the treatment at home.

▸ Nonverbal encouragement and verbal praise help build the self-confidence necessary to carry out the plan.

There also are several basic asthma concepts that must be understood by patients, if they are to use therapies successfully and control asthma triggers.

“I try to limit it to two or three key messages per visit,” said Dr. Cabana, adding that he distributes and reinforces the messages over time through discussions and handouts.

The topics include:

▸ What happens during an asthma attack.

▸ How medicines work.

▸ How to take the medicines.

▸ How to respond to changes in asthma severity.

▸ Medication safety.

▸ Goals of therapy.

▸ Criteria for successful treatment.

▸ Managing asthma at school.

▸ Identifying and avoiding triggers.

▸ Referral for further education.

Many patients and families have questions about steroids because this topic comes up frequently in the media. The key is to ask what the specific concerns are. It may be necessary to point out the differences between anabolic steroids and anti-inflammatory corticosteroids or address growth concerns.

The use of 64-slice multidetector computed tomography (64-MDCT) offers a number of advantages in the evaluation of head and neck trauma in the emergency department—as in the case of the 37-year-old woman imaged above—according to Dr. Osamu Sakai, director of head and neck imaging at Boston Medical Center where 64-MDCT is used in the level I trauma center.

Several images can be acquired simultaneously with 64-MDCT, allowing for faster scans in trauma cases and resulting in earlier therapy and reduced mortality. In addition, 64-MDCT reduces motion artifacts, sharpening multiplanar images and 3D reconstructions.

Thinner slices can be achieved with 64-MDCT, meaning that voxels approach the same size in all dimensions (isotropy). Isotropic voxels allow cross-sectional images to be reconstructed in arbitrary planes, allowing physicians to choose the best views. In addition, spatial resolution with 64-MDCT is in the submillimeter range. Increased resolution decreases partial volume effect caused by having more than one tissue type within the voxel. Partial volume effect results in voxels with average radiodensities of all of the tissue types present in the voxel and may thus be hard to interpret.

For CT angiography (CTA), 64-MDCT's faster scans result in less venous contamination, the superimposition of venous structures on the image that can occur when scanning times are slower because contrast material has time to reach the veins. While scan delay time after intravenous contrast injection is unchanged, the total dose of contrast may be reduced. Requests for CTA have increased dramatically since the introduction of 64-MDCT, according to Dr. Sakai, also of Boston University. CTA using 64-MDCT is now a first-line study for patients with suspected vascular injury and subarachnoid hemorrhage because faster scan times reduce artifacts, such as venous contamination.

The woman imaged above was ejected from her vehicle as the result of a collision, resulting in multiple skull base fractures. Volume-rendering CTA demonstrates an intact circle of Willis (images g and h). Volume-rendering CT venography reveals thrombosed distal right transverse and sigmoid sinuses and jugular bulb/vein (left image).

“Almost all stable patients with penetrating injuries, fractures of skull base and cervical spine, or other clinically suspected vascular injuries undergo CTA with 64-MDCT at our institution,” wrote Dr. Sakai and his colleagues in a poster presented at the 2006 annual meeting of the American Society of Neuroradiology.

Finally, 64-MDCT can “unfuse” or retrospectively produce thinner axial images provided there are sufficient raw data. Abnormalities that aren't picked up on routine 5-mm sections can pop out when reviewed at 1.25-mm or 0.625-mm thickness and spacing, providing additional information to physicians and can be crucial when trauma is not clinically suspected, according to Dr. Sakai.

The use of 64-slice multidetector computed tomography (64-MDCT) offers a number of advantages in the evaluation of head and neck trauma in the emergency department—as in the case of the 37-year-old woman imaged above—according to Dr. Osamu Sakai, director of head and neck imaging at Boston Medical Center where 64-MDCT is used in the level I trauma center.

Several images can be acquired simultaneously with 64-MDCT, allowing for faster scans in trauma cases and resulting in earlier therapy and reduced mortality. In addition, 64-MDCT reduces motion artifacts, sharpening multiplanar images and 3D reconstructions.

Thinner slices can be achieved with 64-MDCT, meaning that voxels approach the same size in all dimensions (isotropy). Isotropic voxels allow cross-sectional images to be reconstructed in arbitrary planes, allowing physicians to choose the best views. In addition, spatial resolution with 64-MDCT is in the submillimeter range. Increased resolution decreases partial volume effect caused by having more than one tissue type within the voxel. Partial volume effect results in voxels with average radiodensities of all of the tissue types present in the voxel and may thus be hard to interpret.

For CT angiography (CTA), 64-MDCT's faster scans result in less venous contamination, the superimposition of venous structures on the image that can occur when scanning times are slower because contrast material has time to reach the veins. While scan delay time after intravenous contrast injection is unchanged, the total dose of contrast may be reduced. Requests for CTA have increased dramatically since the introduction of 64-MDCT, according to Dr. Sakai, also of Boston University. CTA using 64-MDCT is now a first-line study for patients with suspected vascular injury and subarachnoid hemorrhage because faster scan times reduce artifacts, such as venous contamination.

The woman imaged above was ejected from her vehicle as the result of a collision, resulting in multiple skull base fractures. Volume-rendering CTA demonstrates an intact circle of Willis (images g and h). Volume-rendering CT venography reveals thrombosed distal right transverse and sigmoid sinuses and jugular bulb/vein (left image).

“Almost all stable patients with penetrating injuries, fractures of skull base and cervical spine, or other clinically suspected vascular injuries undergo CTA with 64-MDCT at our institution,” wrote Dr. Sakai and his colleagues in a poster presented at the 2006 annual meeting of the American Society of Neuroradiology.

Finally, 64-MDCT can “unfuse” or retrospectively produce thinner axial images provided there are sufficient raw data. Abnormalities that aren't picked up on routine 5-mm sections can pop out when reviewed at 1.25-mm or 0.625-mm thickness and spacing, providing additional information to physicians and can be crucial when trauma is not clinically suspected, according to Dr. Sakai.

The use of 64-slice multidetector computed tomography (64-MDCT) offers a number of advantages in the evaluation of head and neck trauma in the emergency department—as in the case of the 37-year-old woman imaged above—according to Dr. Osamu Sakai, director of head and neck imaging at Boston Medical Center where 64-MDCT is used in the level I trauma center.

Several images can be acquired simultaneously with 64-MDCT, allowing for faster scans in trauma cases and resulting in earlier therapy and reduced mortality. In addition, 64-MDCT reduces motion artifacts, sharpening multiplanar images and 3D reconstructions.

Thinner slices can be achieved with 64-MDCT, meaning that voxels approach the same size in all dimensions (isotropy). Isotropic voxels allow cross-sectional images to be reconstructed in arbitrary planes, allowing physicians to choose the best views. In addition, spatial resolution with 64-MDCT is in the submillimeter range. Increased resolution decreases partial volume effect caused by having more than one tissue type within the voxel. Partial volume effect results in voxels with average radiodensities of all of the tissue types present in the voxel and may thus be hard to interpret.

For CT angiography (CTA), 64-MDCT's faster scans result in less venous contamination, the superimposition of venous structures on the image that can occur when scanning times are slower because contrast material has time to reach the veins. While scan delay time after intravenous contrast injection is unchanged, the total dose of contrast may be reduced. Requests for CTA have increased dramatically since the introduction of 64-MDCT, according to Dr. Sakai, also of Boston University. CTA using 64-MDCT is now a first-line study for patients with suspected vascular injury and subarachnoid hemorrhage because faster scan times reduce artifacts, such as venous contamination.

The woman imaged above was ejected from her vehicle as the result of a collision, resulting in multiple skull base fractures. Volume-rendering CTA demonstrates an intact circle of Willis (images g and h). Volume-rendering CT venography reveals thrombosed distal right transverse and sigmoid sinuses and jugular bulb/vein (left image).

“Almost all stable patients with penetrating injuries, fractures of skull base and cervical spine, or other clinically suspected vascular injuries undergo CTA with 64-MDCT at our institution,” wrote Dr. Sakai and his colleagues in a poster presented at the 2006 annual meeting of the American Society of Neuroradiology.

Finally, 64-MDCT can “unfuse” or retrospectively produce thinner axial images provided there are sufficient raw data. Abnormalities that aren't picked up on routine 5-mm sections can pop out when reviewed at 1.25-mm or 0.625-mm thickness and spacing, providing additional information to physicians and can be crucial when trauma is not clinically suspected, according to Dr. Sakai.