Markette Smith

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

Improving psoriasis outcomes with the use of topical treatments is largely dependent on patient compliance, according to Dr. Joseph S. Eastern.

"In other words, you can have the best treatment in the world, but if a patient doesn't apply it, then it's not going to work," Dr. Eastern said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

Compliance has to be discussed with patients before treatment effectiveness is even addressed. Tachyphylaxis, or the decrease in a patient's response to a drug or active agent with increased use, may often be cited as the reason why a topical treatment is not effective. But the new line of thinking should be "the less you use the steroid, the less it works," said Dr. Eastern, who practices dermatology and dermatologic surgery in Belleville, N.J.

To support this assertion, Dr. Eastern noted a study that assessed adherence in 30 patients with psoriasis. In this university-based clinical trial, the participants were asked to apply 6% salicylic acid twice a day and fill out an at-home log to record their medication activity. The patients were told they were going to be monitored but not informed the individual medication bottles would be encrypted with a microchip in the caps that could record each day and time the bottle was opened. MEMS (Medication Electronic Monitoring System) caps were used for this purpose (J. Am. Acad. Dermatol. 2004;51:212-6).

The participants recorded higher compliance than what was actually recorded by the MEMS caps, with the exception of one participant whose self-reporting mirrored that of the electronic MEMS data. Eighty percent of patients used the product less than they noted in their compliance log. After only 4 days of treatment, the compliance rate dropped to 60%, and there was another 20% drop in compliance after 5 weeks of treatment.

"If this is what 'highly motivated patients' are doing, patients who are being paid to be in the study and were told they are being monitored, what do you think your patients in a private practice are doing? Do you think they are doing better than these university trial patients? Not bloody likely," Dr. Eastern said.

The study did find that there was a spike in use 1-2 weeks before a follow-up office visit. Dr. Eastern referred to this as the "floss effect," noting that people tend to floss a couple days prior to a dentist appointment.

"What works best is follow-up patient visits," he said. "You have to get them back fairly frequently and re-motivate them." Dr. Eastern admitted that regular follow ups can be difficult, as some insurance plans simply will not cover frequent visits.

Follow-up visits also can help physicians learn about any over-the-counter treatments patients are using and provide guidance on which treatments have a greater incidence of efficacy versus others that have no proven effects.

While a combination of drug efficiency, patient compliance, and regularly scheduled follow-up visits is the best recipe for a successful outcome, the only factors in determining efficacy of topical medications are "compliance, compliance, compliance," said Dr. Eastern.

Dr. Eastern reported the following disclosures: Abbott, Aqua Pharmaceuticals, Amgen, Galderma, Genentech, Graceway Pharmaceuticals, Medicis, Quinnova Pharmaceuticals, and Warner Chilcott. SDEF and this news organization are owned by Elsevier.

In the weeks following the massive earthquake in Haiti on Jan. 12, Dr. Alix Charles, a first-generation American of Haitian descent, worried that international concern for the country’s long-term medical and economic needs would wane as the aftershocks abated.

Relieved to know that his immediate relatives back in Haiti all had survived the devastating quake, Dr. Charles shifted his focus to the rebuilding of Haiti, which includes its medical programs.

“Pretty soon people’s minds are going to shift, but I do hope that they will continue to think about Haiti and continue to make contributions; not just monetary, but whatever contributions they can,” said Dr. Charles, who practices dermatology in Hinsdale, Ill.

Over the past 6 years, Dr. Charles has made several trips to Haiti on volunteer medical missions with the American Academy of Dermatology through its Education and Volunteers Abroad Committee. Led by academy members Dr. James J. Nordlund and Dr. James O. Ertle, also a dermatologist in Hinsdale, Dr. Charles would travel with the committee to Leogane (about 20 miles west of Port-au-Prince) to provide dermatologic education to local medical practitioners.

“The whole goal in going down there and we’ve been going down since 2001 is to set up teaching programs,” said Dr. Nordlund, who practices dermatology in Cincinnati. Most dermatologic care in Haiti is provided by family practitioners who have no background or training in the specialty, said Dr. Nordlund. “So they really don’t know how to make the diagnosis. And they guess, and sometimes they get it right, but sometimes they don’t.”

The physicians, through their semiannual trips to Leogane, teach local health care professionals – from residents to nursing students – how to diagnose and treat the 15 most common skin conditions found in developing countries, including fungal infections, eczema, scabies, herpes, cold sores, and shingles. By concentrating on the most prevalent conditions, they are helping the local providers to treat about 80% of the skin problems presented by patients in Haiti, Dr. Nordlund said.

Dr. Nordlund, Dr. Charles, and other members of the committee also helped to establish a dermatologic pharmacy at Cardinal Leger Hospital in Leogane, a small facility run by fewer than a dozen nuns. Unfortunately, the devastation caused by the recent earthquake left most of the facilities in ruins.

“The hospital and the home where the sisters lived – that’s all destroyed ... just demolished, flat on the ground,” said Dr. Nordlund. But the clinic in which they had the pharmacy and the facilities to take care of patients is still intact.

Even with the news that some of the clinics where they had worked were spared in the earthquake, Dr. Charles said he still felt uneasy. “I was terribly worried for the people I knew on the ground,” he said. “I knew this was only going to amplify their need for medical care, and obviously emergency assistance,” said Dr. Charles.

But, with his 2010 mission to Haiti postponed, Dr. Charles said he hopes the exchange of medical information and expertise will not be lost in the urgency to provide emergency care to the stricken region.

“I try to encourage people, if they go down and administer care, to try to also teach a little bit, so that the knowledge and skills don’t leave the island with them.”

Dr. Nordlund says he is planning to return in the fall to launch a dermatology lecture series at the Université d’Etat d’Haiti in Port-au-Prince – the first program of its kind to be taught at the medical school.

But the American Medical Association warns physicians interested volunteering in Haiti to keep in mind the desperate conditions. “Physicians must be prepared to provide care in a physically challenging, austere, resource-constrained environment,” reads a statement on their Web site. The association encourages all physicians considering taking part in the relief effort to read the Disaster Medicine and Public Health Preparedness journal, which can be accessed online at www.dmphp.org.

For now, Dr. Charles rests stateside with thoughts of Haiti in his heart and mind.

“There’s a lot that Haiti’s going to need to rebuild, and the same goes for medical care, and in particular medical education.”

_{Photo courtesy Dr. Alix Charles}

In the weeks following the massive earthquake in Haiti on Jan. 12, Dr. Alix Charles, a first-generation American of Haitian descent, worried that international concern for the country’s long-term medical and economic needs would wane as the aftershocks abated.

Relieved to know that his immediate relatives back in Haiti all had survived the devastating quake, Dr. Charles shifted his focus to the rebuilding of Haiti, which includes its medical programs.

“Pretty soon people’s minds are going to shift, but I do hope that they will continue to think about Haiti and continue to make contributions; not just monetary, but whatever contributions they can,” said Dr. Charles, who practices dermatology in Hinsdale, Ill.

Over the past 6 years, Dr. Charles has made several trips to Haiti on volunteer medical missions with the American Academy of Dermatology through its Education and Volunteers Abroad Committee. Led by academy members Dr. James J. Nordlund and Dr. James O. Ertle, also a dermatologist in Hinsdale, Dr. Charles would travel with the committee to Leogane (about 20 miles west of Port-au-Prince) to provide dermatologic education to local medical practitioners.

“The whole goal in going down there and we’ve been going down since 2001 is to set up teaching programs,” said Dr. Nordlund, who practices dermatology in Cincinnati. Most dermatologic care in Haiti is provided by family practitioners who have no background or training in the specialty, said Dr. Nordlund. “So they really don’t know how to make the diagnosis. And they guess, and sometimes they get it right, but sometimes they don’t.”

The physicians, through their semiannual trips to Leogane, teach local health care professionals – from residents to nursing students – how to diagnose and treat the 15 most common skin conditions found in developing countries, including fungal infections, eczema, scabies, herpes, cold sores, and shingles. By concentrating on the most prevalent conditions, they are helping the local providers to treat about 80% of the skin problems presented by patients in Haiti, Dr. Nordlund said.

Dr. Nordlund, Dr. Charles, and other members of the committee also helped to establish a dermatologic pharmacy at Cardinal Leger Hospital in Leogane, a small facility run by fewer than a dozen nuns. Unfortunately, the devastation caused by the recent earthquake left most of the facilities in ruins.

“The hospital and the home where the sisters lived – that’s all destroyed ... just demolished, flat on the ground,” said Dr. Nordlund. But the clinic in which they had the pharmacy and the facilities to take care of patients is still intact.

Even with the news that some of the clinics where they had worked were spared in the earthquake, Dr. Charles said he still felt uneasy. “I was terribly worried for the people I knew on the ground,” he said. “I knew this was only going to amplify their need for medical care, and obviously emergency assistance,” said Dr. Charles.

But, with his 2010 mission to Haiti postponed, Dr. Charles said he hopes the exchange of medical information and expertise will not be lost in the urgency to provide emergency care to the stricken region.

“I try to encourage people, if they go down and administer care, to try to also teach a little bit, so that the knowledge and skills don’t leave the island with them.”

Dr. Nordlund says he is planning to return in the fall to launch a dermatology lecture series at the Université d’Etat d’Haiti in Port-au-Prince – the first program of its kind to be taught at the medical school.

But the American Medical Association warns physicians interested volunteering in Haiti to keep in mind the desperate conditions. “Physicians must be prepared to provide care in a physically challenging, austere, resource-constrained environment,” reads a statement on their Web site. The association encourages all physicians considering taking part in the relief effort to read the Disaster Medicine and Public Health Preparedness journal, which can be accessed online at www.dmphp.org.

For now, Dr. Charles rests stateside with thoughts of Haiti in his heart and mind.

“There’s a lot that Haiti’s going to need to rebuild, and the same goes for medical care, and in particular medical education.”

_{Photo courtesy Dr. Alix Charles}

In the weeks following the massive earthquake in Haiti on Jan. 12, Dr. Alix Charles, a first-generation American of Haitian descent, worried that international concern for the country’s long-term medical and economic needs would wane as the aftershocks abated.

Relieved to know that his immediate relatives back in Haiti all had survived the devastating quake, Dr. Charles shifted his focus to the rebuilding of Haiti, which includes its medical programs.

“Pretty soon people’s minds are going to shift, but I do hope that they will continue to think about Haiti and continue to make contributions; not just monetary, but whatever contributions they can,” said Dr. Charles, who practices dermatology in Hinsdale, Ill.

Over the past 6 years, Dr. Charles has made several trips to Haiti on volunteer medical missions with the American Academy of Dermatology through its Education and Volunteers Abroad Committee. Led by academy members Dr. James J. Nordlund and Dr. James O. Ertle, also a dermatologist in Hinsdale, Dr. Charles would travel with the committee to Leogane (about 20 miles west of Port-au-Prince) to provide dermatologic education to local medical practitioners.

“The whole goal in going down there and we’ve been going down since 2001 is to set up teaching programs,” said Dr. Nordlund, who practices dermatology in Cincinnati. Most dermatologic care in Haiti is provided by family practitioners who have no background or training in the specialty, said Dr. Nordlund. “So they really don’t know how to make the diagnosis. And they guess, and sometimes they get it right, but sometimes they don’t.”

The physicians, through their semiannual trips to Leogane, teach local health care professionals – from residents to nursing students – how to diagnose and treat the 15 most common skin conditions found in developing countries, including fungal infections, eczema, scabies, herpes, cold sores, and shingles. By concentrating on the most prevalent conditions, they are helping the local providers to treat about 80% of the skin problems presented by patients in Haiti, Dr. Nordlund said.

Dr. Nordlund, Dr. Charles, and other members of the committee also helped to establish a dermatologic pharmacy at Cardinal Leger Hospital in Leogane, a small facility run by fewer than a dozen nuns. Unfortunately, the devastation caused by the recent earthquake left most of the facilities in ruins.

“The hospital and the home where the sisters lived – that’s all destroyed ... just demolished, flat on the ground,” said Dr. Nordlund. But the clinic in which they had the pharmacy and the facilities to take care of patients is still intact.

Even with the news that some of the clinics where they had worked were spared in the earthquake, Dr. Charles said he still felt uneasy. “I was terribly worried for the people I knew on the ground,” he said. “I knew this was only going to amplify their need for medical care, and obviously emergency assistance,” said Dr. Charles.

But, with his 2010 mission to Haiti postponed, Dr. Charles said he hopes the exchange of medical information and expertise will not be lost in the urgency to provide emergency care to the stricken region.

“I try to encourage people, if they go down and administer care, to try to also teach a little bit, so that the knowledge and skills don’t leave the island with them.”

Dr. Nordlund says he is planning to return in the fall to launch a dermatology lecture series at the Université d’Etat d’Haiti in Port-au-Prince – the first program of its kind to be taught at the medical school.

But the American Medical Association warns physicians interested volunteering in Haiti to keep in mind the desperate conditions. “Physicians must be prepared to provide care in a physically challenging, austere, resource-constrained environment,” reads a statement on their Web site. The association encourages all physicians considering taking part in the relief effort to read the Disaster Medicine and Public Health Preparedness journal, which can be accessed online at www.dmphp.org.

For now, Dr. Charles rests stateside with thoughts of Haiti in his heart and mind.

“There’s a lot that Haiti’s going to need to rebuild, and the same goes for medical care, and in particular medical education.”

_{Photo courtesy Dr. Alix Charles}

Ginkgo biloba shows no notable effect in reducing the incidence of dementia caused by Alzheimer's disease or dementia overall in older adults when compared with placebo, results of a recent study of more than 3,000 older adults show.

The latest findings are consistent with smaller trials, Beth E. Snitz, Ph.D., and her colleagues reported (JAMA 2009;302:2663–70).

In the current study, adults aged 72–96 years were monitored at six medical centers in the United States between 2000 and 2008 in the largest completed randomized, double-blind, placebo-controlled dementia prevention trial to date, according to Dr. Snitz, of the department of neurology at the University of Pittsburgh, and her colleagues. A total of 60% of subjects successfully completed the study; 54% were men.

Of the total, 1,545 participants were randomized to receive a 120-mg dose of ginkgo biloba extract and 1,524 to receive placebo twice a day, Dr. Snitz noted. Follow-up included neuropsychological testing every 6 months until 2004 and once a year thereafter. The median follow-up was 6.1 years.

The placebo group performed better than did the ginkgo biloba group on 3 of 12 neuropsychological tests administered at baseline. Scores on other tests did not differ by treatment group. The ginkgo biloba and placebo groups did not differ on rates of cognitive change for the global cognition score or cognitive domains tested (memory, attention, visuospatial abilities, language, and executive functions).

In year 6 of the study, a secondary analysis was taken and results were consistent with the primary analysis; rates of cognitive change for the global score and all cognitive domains did not differ by treatment group, the investigators noted. In participants with early dementia or symptoms of cognitive impairment, results also indicated that 3 to 4 years of ginkgo biloba treatment had no significant effect on cognitive decline 2 to 3 years after use.

The clinical meaning of cognitive decline in this study was defined by a 4-point change in the Alzheimer Disease Scale.

“We [found] no evidence that G. biloba slows the rate of cognitive decline in older adults,” wrote the investigators. “These findings are consistent with previous smaller studies examining prevention of decline and facilitation of cognitive performance and with the 2009 Cochrane review of G. biloba for dementia and cognitive impairment.”

Funding for the study was provided in part through a grant from the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health. Ginkgo biloba extract tablets and placebo tablets were donated by Schwabe Pharmaceuticals.

Dr. Snitz and colleagues reported no relevant conflicts of interest.

Ginkgo biloba shows no notable effect in reducing the incidence of dementia caused by Alzheimer's disease or dementia overall in older adults when compared with placebo, results of a recent study of more than 3,000 older adults show.

The latest findings are consistent with smaller trials, Beth E. Snitz, Ph.D., and her colleagues reported (JAMA 2009;302:2663–70).

In the current study, adults aged 72–96 years were monitored at six medical centers in the United States between 2000 and 2008 in the largest completed randomized, double-blind, placebo-controlled dementia prevention trial to date, according to Dr. Snitz, of the department of neurology at the University of Pittsburgh, and her colleagues. A total of 60% of subjects successfully completed the study; 54% were men.

Of the total, 1,545 participants were randomized to receive a 120-mg dose of ginkgo biloba extract and 1,524 to receive placebo twice a day, Dr. Snitz noted. Follow-up included neuropsychological testing every 6 months until 2004 and once a year thereafter. The median follow-up was 6.1 years.

The placebo group performed better than did the ginkgo biloba group on 3 of 12 neuropsychological tests administered at baseline. Scores on other tests did not differ by treatment group. The ginkgo biloba and placebo groups did not differ on rates of cognitive change for the global cognition score or cognitive domains tested (memory, attention, visuospatial abilities, language, and executive functions).

In year 6 of the study, a secondary analysis was taken and results were consistent with the primary analysis; rates of cognitive change for the global score and all cognitive domains did not differ by treatment group, the investigators noted. In participants with early dementia or symptoms of cognitive impairment, results also indicated that 3 to 4 years of ginkgo biloba treatment had no significant effect on cognitive decline 2 to 3 years after use.

The clinical meaning of cognitive decline in this study was defined by a 4-point change in the Alzheimer Disease Scale.

“We [found] no evidence that G. biloba slows the rate of cognitive decline in older adults,” wrote the investigators. “These findings are consistent with previous smaller studies examining prevention of decline and facilitation of cognitive performance and with the 2009 Cochrane review of G. biloba for dementia and cognitive impairment.”

Funding for the study was provided in part through a grant from the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health. Ginkgo biloba extract tablets and placebo tablets were donated by Schwabe Pharmaceuticals.

Dr. Snitz and colleagues reported no relevant conflicts of interest.

Ginkgo biloba shows no notable effect in reducing the incidence of dementia caused by Alzheimer's disease or dementia overall in older adults when compared with placebo, results of a recent study of more than 3,000 older adults show.

The latest findings are consistent with smaller trials, Beth E. Snitz, Ph.D., and her colleagues reported (JAMA 2009;302:2663–70).

In the current study, adults aged 72–96 years were monitored at six medical centers in the United States between 2000 and 2008 in the largest completed randomized, double-blind, placebo-controlled dementia prevention trial to date, according to Dr. Snitz, of the department of neurology at the University of Pittsburgh, and her colleagues. A total of 60% of subjects successfully completed the study; 54% were men.

Of the total, 1,545 participants were randomized to receive a 120-mg dose of ginkgo biloba extract and 1,524 to receive placebo twice a day, Dr. Snitz noted. Follow-up included neuropsychological testing every 6 months until 2004 and once a year thereafter. The median follow-up was 6.1 years.

The placebo group performed better than did the ginkgo biloba group on 3 of 12 neuropsychological tests administered at baseline. Scores on other tests did not differ by treatment group. The ginkgo biloba and placebo groups did not differ on rates of cognitive change for the global cognition score or cognitive domains tested (memory, attention, visuospatial abilities, language, and executive functions).

In year 6 of the study, a secondary analysis was taken and results were consistent with the primary analysis; rates of cognitive change for the global score and all cognitive domains did not differ by treatment group, the investigators noted. In participants with early dementia or symptoms of cognitive impairment, results also indicated that 3 to 4 years of ginkgo biloba treatment had no significant effect on cognitive decline 2 to 3 years after use.

The clinical meaning of cognitive decline in this study was defined by a 4-point change in the Alzheimer Disease Scale.

“We [found] no evidence that G. biloba slows the rate of cognitive decline in older adults,” wrote the investigators. “These findings are consistent with previous smaller studies examining prevention of decline and facilitation of cognitive performance and with the 2009 Cochrane review of G. biloba for dementia and cognitive impairment.”

Funding for the study was provided in part through a grant from the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health. Ginkgo biloba extract tablets and placebo tablets were donated by Schwabe Pharmaceuticals.

Dr. Snitz and colleagues reported no relevant conflicts of interest.

Reduced doses of psoriasis treatment, when mixed with placebo, are just as effective as standard therapy for preventing relapse and reducing severity, a new randomized, double-blind study found.

The study, recently published online in Psychosomatic Medicine, was modeled after the concept of classical conditioning in which a subject can be trained to react to a stimulant. Investigators hypothesized that psoriasis patients could be conditioned toward better outcomes by being told they were receiving a higher dosage or more frequent corticosteroid reinforcement than they actually were.

Forty-six patients (83% white and 56% male) with mild to moderate psoriasis were divided into three groups. The standard-therapy group (18 patients) received continuous reinforcement of 0.1% triamcinolone acetonide (Aristocort A) twice daily to a randomly selected target lesion, while a commercial moisturizing cream was applied to a comparable control lesion, reported Robert Ader, Ph.D. and his colleagues.

Patients in the partial-reinforcement group (15 patients) received the same 0.1% dose of Aristocort A as the standard therapy group, but in only a portion of the syringes administered to them for treatment. The remainder of the syringes contained a placebo ointment of the same color and fragrance as the standard reinforcement. The investigators dubbed the ointment the “conditioned stimuli.”

The dose-control group (13 patients) received continuous reinforcement throughout the trial, but with only 25% or 50% of the active ingredient administered in each dosage, noted Dr. Ader of the department of psychiatry at the University of Rochester (N.Y.), and his colleagues.

Approximately half the patients were studied at the University of Rochester and the other half at Stanford (Calif.) University between 2001 and 2006.

Evaluations of the psoriatic lesions were made weekly throughout the maintenance (conditioning) period and experimental period by a blinded dermatologist (Psychosom. Med. 2009 Dec. 22 [doi:10.1097/PSY.0b013e3181cbd38b]).

Initially, there were no differences in the severity between target and control lesions on patients in all groups, but during the 8-week experimental period, 61.5% of patients in the dose-control group relapsed, while only 22.2% of patients in the standard-therapy group relapsed. The incidence of relapse in the partial-reinforcement group was 26.7%.

Researchers in New York did find, however, that final severity outcomes measured by a modified Psoriasis Severity Scale produced no differences between the partial reinforcement group and the standard therapy group, even though patients in the latter received two to four times more active ingredient.

Psoriasis severity in Rochester’s dose-control group saw a steady increase throughout the 8-week experimental period (patients saw 44% less improvement between target and control lesions, compared with the partial reinforcement group). In California, disease severity outcomes neither supported nor refuted the hypothesis.

“A partial schedule of pharmacotherapeutic reinforcement could maintain psoriasis patients with a cumulative amount of corticosteroid that was relatively ineffective when administered under standard treatment conditions,” wrote Dr. Ader and his investigators. “Conceivably, corticosteroid administration only one quarter or half as frequently as currently prescribed is sufficient to treat psoriasis.”

Dr. Ader and his colleagues reported no conflicts of interest. The study was supported, in part, by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Center for Complementary and Alternative Medicine.

Reduced doses of psoriasis treatment, when mixed with placebo, are just as effective as standard therapy for preventing relapse and reducing severity, a new randomized, double-blind study found.

The study, recently published online in Psychosomatic Medicine, was modeled after the concept of classical conditioning in which a subject can be trained to react to a stimulant. Investigators hypothesized that psoriasis patients could be conditioned toward better outcomes by being told they were receiving a higher dosage or more frequent corticosteroid reinforcement than they actually were.

Forty-six patients (83% white and 56% male) with mild to moderate psoriasis were divided into three groups. The standard-therapy group (18 patients) received continuous reinforcement of 0.1% triamcinolone acetonide (Aristocort A) twice daily to a randomly selected target lesion, while a commercial moisturizing cream was applied to a comparable control lesion, reported Robert Ader, Ph.D. and his colleagues.

Patients in the partial-reinforcement group (15 patients) received the same 0.1% dose of Aristocort A as the standard therapy group, but in only a portion of the syringes administered to them for treatment. The remainder of the syringes contained a placebo ointment of the same color and fragrance as the standard reinforcement. The investigators dubbed the ointment the “conditioned stimuli.”

The dose-control group (13 patients) received continuous reinforcement throughout the trial, but with only 25% or 50% of the active ingredient administered in each dosage, noted Dr. Ader of the department of psychiatry at the University of Rochester (N.Y.), and his colleagues.

Approximately half the patients were studied at the University of Rochester and the other half at Stanford (Calif.) University between 2001 and 2006.

Evaluations of the psoriatic lesions were made weekly throughout the maintenance (conditioning) period and experimental period by a blinded dermatologist (Psychosom. Med. 2009 Dec. 22 [doi:10.1097/PSY.0b013e3181cbd38b]).

Initially, there were no differences in the severity between target and control lesions on patients in all groups, but during the 8-week experimental period, 61.5% of patients in the dose-control group relapsed, while only 22.2% of patients in the standard-therapy group relapsed. The incidence of relapse in the partial-reinforcement group was 26.7%.

Researchers in New York did find, however, that final severity outcomes measured by a modified Psoriasis Severity Scale produced no differences between the partial reinforcement group and the standard therapy group, even though patients in the latter received two to four times more active ingredient.

Psoriasis severity in Rochester’s dose-control group saw a steady increase throughout the 8-week experimental period (patients saw 44% less improvement between target and control lesions, compared with the partial reinforcement group). In California, disease severity outcomes neither supported nor refuted the hypothesis.

“A partial schedule of pharmacotherapeutic reinforcement could maintain psoriasis patients with a cumulative amount of corticosteroid that was relatively ineffective when administered under standard treatment conditions,” wrote Dr. Ader and his investigators. “Conceivably, corticosteroid administration only one quarter or half as frequently as currently prescribed is sufficient to treat psoriasis.”

Dr. Ader and his colleagues reported no conflicts of interest. The study was supported, in part, by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Center for Complementary and Alternative Medicine.

Reduced doses of psoriasis treatment, when mixed with placebo, are just as effective as standard therapy for preventing relapse and reducing severity, a new randomized, double-blind study found.

The study, recently published online in Psychosomatic Medicine, was modeled after the concept of classical conditioning in which a subject can be trained to react to a stimulant. Investigators hypothesized that psoriasis patients could be conditioned toward better outcomes by being told they were receiving a higher dosage or more frequent corticosteroid reinforcement than they actually were.

Forty-six patients (83% white and 56% male) with mild to moderate psoriasis were divided into three groups. The standard-therapy group (18 patients) received continuous reinforcement of 0.1% triamcinolone acetonide (Aristocort A) twice daily to a randomly selected target lesion, while a commercial moisturizing cream was applied to a comparable control lesion, reported Robert Ader, Ph.D. and his colleagues.

Patients in the partial-reinforcement group (15 patients) received the same 0.1% dose of Aristocort A as the standard therapy group, but in only a portion of the syringes administered to them for treatment. The remainder of the syringes contained a placebo ointment of the same color and fragrance as the standard reinforcement. The investigators dubbed the ointment the “conditioned stimuli.”

The dose-control group (13 patients) received continuous reinforcement throughout the trial, but with only 25% or 50% of the active ingredient administered in each dosage, noted Dr. Ader of the department of psychiatry at the University of Rochester (N.Y.), and his colleagues.

Approximately half the patients were studied at the University of Rochester and the other half at Stanford (Calif.) University between 2001 and 2006.

Evaluations of the psoriatic lesions were made weekly throughout the maintenance (conditioning) period and experimental period by a blinded dermatologist (Psychosom. Med. 2009 Dec. 22 [doi:10.1097/PSY.0b013e3181cbd38b]).

Initially, there were no differences in the severity between target and control lesions on patients in all groups, but during the 8-week experimental period, 61.5% of patients in the dose-control group relapsed, while only 22.2% of patients in the standard-therapy group relapsed. The incidence of relapse in the partial-reinforcement group was 26.7%.

Researchers in New York did find, however, that final severity outcomes measured by a modified Psoriasis Severity Scale produced no differences between the partial reinforcement group and the standard therapy group, even though patients in the latter received two to four times more active ingredient.

Psoriasis severity in Rochester’s dose-control group saw a steady increase throughout the 8-week experimental period (patients saw 44% less improvement between target and control lesions, compared with the partial reinforcement group). In California, disease severity outcomes neither supported nor refuted the hypothesis.

“A partial schedule of pharmacotherapeutic reinforcement could maintain psoriasis patients with a cumulative amount of corticosteroid that was relatively ineffective when administered under standard treatment conditions,” wrote Dr. Ader and his investigators. “Conceivably, corticosteroid administration only one quarter or half as frequently as currently prescribed is sufficient to treat psoriasis.”

Dr. Ader and his colleagues reported no conflicts of interest. The study was supported, in part, by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Center for Complementary and Alternative Medicine.

Counties with the highest rates of obesity and diabetes are disproportionately located in the Southeast and western Appalachian regions of the United States, according to a survey from the Centers for Disease Control and Prevention.

Over 80% of counties in the Appalachian regions of Kentucky, Tennessee, and West Virginia reported high rates of obesity and diabetes, while three-fourths of counties in Alabama, Georgia, Louisiana, Mississippi, and South Carolina reported similarly high rates, according to the CDC.

“Isolated counties, including tribal lands in the western United States, also had high prevalence of diabetes and obesity,” the researchers wrote (MMWR 2009;58:1259-63).

The results came from a self-reported telephone survey conducted in all 3,141 U.S. counties in 2007. Obesity was defined as a body mass index of 30 kg/m

The 10.6% or higher prevalence of diabetes—the top quintile of survey results—existed primarily in the belt extending from the Mississippi River to the coastal Carolinas and in the Appalachians. In Alabama, Kentucky, Mississippi, South Carolina, and West Virginia, 73% of counties had diabetes rates in the top quintile, and 70% of counties had obesity rates in the top quintile.

On a county level, the prevalence of obesity was highly correlated with the prevalence of diabetes. For example, a county with an obesity rate five percentage points higher than another county also had a diabetes rate that was at least 1.4 percentage points higher.

The strong regional patterns of obesity and diabetes are believed to exist because of a convergence of social norms, community and environmental factors, socioeconomic status, and genetic risk factors, according to researchers. Evidence suggests that successful interventions, particularly for diabetes prevention and control, often depend on efficient referral to local community programs (Am. J. Prev. Med. 2008;35:357-63).

As medical costs associated with obesity reached an estimated $147 billion in 2008 and diabetes costs reached $116 billion, researchers hope the results will help target prevention and intervention efforts to the high-risk regions found in the survey.

“Diabetes is costly in human and economic terms, and it's urgent that we take action to prevent and control this serious disease,” Dr. Ann Albright, director of the CDC's Division of Diabetes Translation, said in a written statement. “The study shows strong regional patterns of diabetes and can help focus prevention efforts where they are most needed.”

The researchers concluded that comprehensive disease surveillance systems are necessary for developing preventive health policies and tracking their impact in high-risk populations.

The report is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5845a2.htm

Counties with the highest rates of obesity and diabetes are disproportionately located in the Southeast and western Appalachian regions of the United States, according to a survey from the Centers for Disease Control and Prevention.

Over 80% of counties in the Appalachian regions of Kentucky, Tennessee, and West Virginia reported high rates of obesity and diabetes, while three-fourths of counties in Alabama, Georgia, Louisiana, Mississippi, and South Carolina reported similarly high rates, according to the CDC.

“Isolated counties, including tribal lands in the western United States, also had high prevalence of diabetes and obesity,” the researchers wrote (MMWR 2009;58:1259-63).

The results came from a self-reported telephone survey conducted in all 3,141 U.S. counties in 2007. Obesity was defined as a body mass index of 30 kg/m

The 10.6% or higher prevalence of diabetes—the top quintile of survey results—existed primarily in the belt extending from the Mississippi River to the coastal Carolinas and in the Appalachians. In Alabama, Kentucky, Mississippi, South Carolina, and West Virginia, 73% of counties had diabetes rates in the top quintile, and 70% of counties had obesity rates in the top quintile.

On a county level, the prevalence of obesity was highly correlated with the prevalence of diabetes. For example, a county with an obesity rate five percentage points higher than another county also had a diabetes rate that was at least 1.4 percentage points higher.

The strong regional patterns of obesity and diabetes are believed to exist because of a convergence of social norms, community and environmental factors, socioeconomic status, and genetic risk factors, according to researchers. Evidence suggests that successful interventions, particularly for diabetes prevention and control, often depend on efficient referral to local community programs (Am. J. Prev. Med. 2008;35:357-63).

As medical costs associated with obesity reached an estimated $147 billion in 2008 and diabetes costs reached $116 billion, researchers hope the results will help target prevention and intervention efforts to the high-risk regions found in the survey.

“Diabetes is costly in human and economic terms, and it's urgent that we take action to prevent and control this serious disease,” Dr. Ann Albright, director of the CDC's Division of Diabetes Translation, said in a written statement. “The study shows strong regional patterns of diabetes and can help focus prevention efforts where they are most needed.”

The researchers concluded that comprehensive disease surveillance systems are necessary for developing preventive health policies and tracking their impact in high-risk populations.

The report is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5845a2.htm

Counties with the highest rates of obesity and diabetes are disproportionately located in the Southeast and western Appalachian regions of the United States, according to a survey from the Centers for Disease Control and Prevention.

Over 80% of counties in the Appalachian regions of Kentucky, Tennessee, and West Virginia reported high rates of obesity and diabetes, while three-fourths of counties in Alabama, Georgia, Louisiana, Mississippi, and South Carolina reported similarly high rates, according to the CDC.

“Isolated counties, including tribal lands in the western United States, also had high prevalence of diabetes and obesity,” the researchers wrote (MMWR 2009;58:1259-63).

The results came from a self-reported telephone survey conducted in all 3,141 U.S. counties in 2007. Obesity was defined as a body mass index of 30 kg/m

The 10.6% or higher prevalence of diabetes—the top quintile of survey results—existed primarily in the belt extending from the Mississippi River to the coastal Carolinas and in the Appalachians. In Alabama, Kentucky, Mississippi, South Carolina, and West Virginia, 73% of counties had diabetes rates in the top quintile, and 70% of counties had obesity rates in the top quintile.

On a county level, the prevalence of obesity was highly correlated with the prevalence of diabetes. For example, a county with an obesity rate five percentage points higher than another county also had a diabetes rate that was at least 1.4 percentage points higher.

The strong regional patterns of obesity and diabetes are believed to exist because of a convergence of social norms, community and environmental factors, socioeconomic status, and genetic risk factors, according to researchers. Evidence suggests that successful interventions, particularly for diabetes prevention and control, often depend on efficient referral to local community programs (Am. J. Prev. Med. 2008;35:357-63).

As medical costs associated with obesity reached an estimated $147 billion in 2008 and diabetes costs reached $116 billion, researchers hope the results will help target prevention and intervention efforts to the high-risk regions found in the survey.

“Diabetes is costly in human and economic terms, and it's urgent that we take action to prevent and control this serious disease,” Dr. Ann Albright, director of the CDC's Division of Diabetes Translation, said in a written statement. “The study shows strong regional patterns of diabetes and can help focus prevention efforts where they are most needed.”

The researchers concluded that comprehensive disease surveillance systems are necessary for developing preventive health policies and tracking their impact in high-risk populations.

The report is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5845a2.htm