Miriam E. Tucker

LAS VEGAS – Minimally invasive surgical staging for endometrial cancer produced outcomes in elderly women similar to those in younger women, according to a chart review of 109 women with clinical stage I disease.

Endometrial cancer is especially prominent in elderly women, with the median age of diagnosis of 63 years; 45% of women are diagnosed at age 65 or older. Although numerous studies have shown that minimally invasive surgery (MIS) is a safe, feasible alternative to laparotomy in the management of endometrial cancer, few data are available regarding MIS approaches to endometrial cancer in the elderly population, said Dr. Melissa K. Frey of New York–Presbyterian Hospital, New York.

In this retrospective study, the 48 patients aged 65 and older had a mean age of 73 years, and the 61 in the younger group had a mean age of 56 years. There were no differences between the older and younger groups in body mass index or number of prior abdominal surgeries. However, the older group did have more major comorbidities (73% vs. 31%).

Laparoscopic procedures were used in 31 elderly patients and 36 younger women, while robotic-assisted laparoscopic procedures were used in 17 older and 25 younger patients, she reported at the meeting.

There were no significant differences in mean surgical time (239 minutes in the younger group vs. 228 in the older), estimated blood loss (187 vs. 159 mL), blood transfusions (2 vs. 1 per patient), surgical complications (4 vs. 2), mean hospital stay (2.4 vs. 2.6 days), or mean number of lymph nodes removed (18 vs. 19).

“Minimally invasive staging of endometrial cancer is feasible and safe in elderly women,” Dr. Frey concluded.

She stated that she had no relevant financial disclosures.

LAS VEGAS – Minimally invasive surgical staging for endometrial cancer produced outcomes in elderly women similar to those in younger women, according to a chart review of 109 women with clinical stage I disease.

Endometrial cancer is especially prominent in elderly women, with the median age of diagnosis of 63 years; 45% of women are diagnosed at age 65 or older. Although numerous studies have shown that minimally invasive surgery (MIS) is a safe, feasible alternative to laparotomy in the management of endometrial cancer, few data are available regarding MIS approaches to endometrial cancer in the elderly population, said Dr. Melissa K. Frey of New York–Presbyterian Hospital, New York.

In this retrospective study, the 48 patients aged 65 and older had a mean age of 73 years, and the 61 in the younger group had a mean age of 56 years. There were no differences between the older and younger groups in body mass index or number of prior abdominal surgeries. However, the older group did have more major comorbidities (73% vs. 31%).

Laparoscopic procedures were used in 31 elderly patients and 36 younger women, while robotic-assisted laparoscopic procedures were used in 17 older and 25 younger patients, she reported at the meeting.

There were no significant differences in mean surgical time (239 minutes in the younger group vs. 228 in the older), estimated blood loss (187 vs. 159 mL), blood transfusions (2 vs. 1 per patient), surgical complications (4 vs. 2), mean hospital stay (2.4 vs. 2.6 days), or mean number of lymph nodes removed (18 vs. 19).

“Minimally invasive staging of endometrial cancer is feasible and safe in elderly women,” Dr. Frey concluded.

She stated that she had no relevant financial disclosures.

LAS VEGAS – Minimally invasive surgical staging for endometrial cancer produced outcomes in elderly women similar to those in younger women, according to a chart review of 109 women with clinical stage I disease.

Endometrial cancer is especially prominent in elderly women, with the median age of diagnosis of 63 years; 45% of women are diagnosed at age 65 or older. Although numerous studies have shown that minimally invasive surgery (MIS) is a safe, feasible alternative to laparotomy in the management of endometrial cancer, few data are available regarding MIS approaches to endometrial cancer in the elderly population, said Dr. Melissa K. Frey of New York–Presbyterian Hospital, New York.

In this retrospective study, the 48 patients aged 65 and older had a mean age of 73 years, and the 61 in the younger group had a mean age of 56 years. There were no differences between the older and younger groups in body mass index or number of prior abdominal surgeries. However, the older group did have more major comorbidities (73% vs. 31%).

Laparoscopic procedures were used in 31 elderly patients and 36 younger women, while robotic-assisted laparoscopic procedures were used in 17 older and 25 younger patients, she reported at the meeting.

There were no significant differences in mean surgical time (239 minutes in the younger group vs. 228 in the older), estimated blood loss (187 vs. 159 mL), blood transfusions (2 vs. 1 per patient), surgical complications (4 vs. 2), mean hospital stay (2.4 vs. 2.6 days), or mean number of lymph nodes removed (18 vs. 19).

“Minimally invasive staging of endometrial cancer is feasible and safe in elderly women,” Dr. Frey concluded.

She stated that she had no relevant financial disclosures.

Major Finding: Duration of surgery was significantly shorter with the barbed suture, 117.6 vs. 161.2 minutes for the smooth suture. The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days.

Data Source: Retrospective analysis of 138 consecutive laparoscopic myomectomy cases.

Disclosures: Dr. Cohen said that the study's principal investigator, Dr. Jon I. Einarsson, is a consultant for Ethicon-Endo Surgery. The authors said they have no financial relationship with the device manufacturer, Angiotech Pharmaceuticals.

LAS VEGAS – Use of bidirectional barbed suture reduced operative time by approximately 40 minutes and decreased the length of hospital stay by half a day in a retrospective comparison to use of conventional smooth suture for closure in laparoscopic myomectomy.

Bidirectional barbed suture, in which barbs are cut into the suture so that they are facing in a direction opposite to that of the needle, are designed to resist migration.

The Quill bidirectional barbed suture (Angiotech Pharmaceuticals) has been commercially available in the United States since 2007.

Anecdotally, use of the barbed suture eliminates backsliding of the suture, thereby facilitating myometrial closure, said Dr. Sarah Cohen of Brigham and Women's Hospital, Boston. Dr. Cohen presented the results of the study, which were subsequently published (J. Minim. Invasive Gynecol. 2011;18:92-5).

Perioperative outcomes for a total of 138 consecutive cases of laparoscopic myomectomy performed by a single surgeon were reviewed, including 31 with conventional smooth suture during February 2007 through March 2008 and 107 cases performed from March 2008 through April 2010 using bidirectional barbed suture.

Aside from the suture choice, operative technique was similar for all cases, Dr. Cohen said at the meeting.

There were no significant differences between the two patient groups in demographic characteristics.

The most common indications for undergoing laparoscopic myomectomy were pelvic pain and/or pressure (in 30 smooth and 81 barbed suture patients) and abnormal uterine bleeding (in 11 and 41). The remainder of patients underwent the procedure for other reasons.

The duration of surgery was significantly shorter with the barbed suture, 117.6 minutes compared with 161.2 minutes for the smooth suture.

The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days. The estimated blood loss, number of myomas removed, and weight of myomas did not differ between the two groups, she reported.

In order to account for any impact of a surgical learning curve, the 31 cases using smooth suture were compared with just the first 31 cases performed after the switch to bidirectional barbed suture. The duration of surgery and the hospital stay were both still significantly shorter with the barbed suture (121.9 minutes and 0.42 days).

There was one intraoperative complication in a patient with the smooth suture, which was unrelated to the suturing. There were no intraoperative complications with the barbed suture.

Postoperative complications among the barbed suture patients included two incision site infections (1.9%), four urinary tract infections (3.7%), one ileus (0.9%), and one blood transfusion (0.9%). In the smooth suture group, there were two UTIs (6.4%). The differences in complication rates were not significant, she noted.

Major Finding: Duration of surgery was significantly shorter with the barbed suture, 117.6 vs. 161.2 minutes for the smooth suture. The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days.

Data Source: Retrospective analysis of 138 consecutive laparoscopic myomectomy cases.

Disclosures: Dr. Cohen said that the study's principal investigator, Dr. Jon I. Einarsson, is a consultant for Ethicon-Endo Surgery. The authors said they have no financial relationship with the device manufacturer, Angiotech Pharmaceuticals.

LAS VEGAS – Use of bidirectional barbed suture reduced operative time by approximately 40 minutes and decreased the length of hospital stay by half a day in a retrospective comparison to use of conventional smooth suture for closure in laparoscopic myomectomy.

Bidirectional barbed suture, in which barbs are cut into the suture so that they are facing in a direction opposite to that of the needle, are designed to resist migration.

The Quill bidirectional barbed suture (Angiotech Pharmaceuticals) has been commercially available in the United States since 2007.

Anecdotally, use of the barbed suture eliminates backsliding of the suture, thereby facilitating myometrial closure, said Dr. Sarah Cohen of Brigham and Women's Hospital, Boston. Dr. Cohen presented the results of the study, which were subsequently published (J. Minim. Invasive Gynecol. 2011;18:92-5).

Perioperative outcomes for a total of 138 consecutive cases of laparoscopic myomectomy performed by a single surgeon were reviewed, including 31 with conventional smooth suture during February 2007 through March 2008 and 107 cases performed from March 2008 through April 2010 using bidirectional barbed suture.

Aside from the suture choice, operative technique was similar for all cases, Dr. Cohen said at the meeting.

There were no significant differences between the two patient groups in demographic characteristics.

The most common indications for undergoing laparoscopic myomectomy were pelvic pain and/or pressure (in 30 smooth and 81 barbed suture patients) and abnormal uterine bleeding (in 11 and 41). The remainder of patients underwent the procedure for other reasons.

The duration of surgery was significantly shorter with the barbed suture, 117.6 minutes compared with 161.2 minutes for the smooth suture.

The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days. The estimated blood loss, number of myomas removed, and weight of myomas did not differ between the two groups, she reported.

In order to account for any impact of a surgical learning curve, the 31 cases using smooth suture were compared with just the first 31 cases performed after the switch to bidirectional barbed suture. The duration of surgery and the hospital stay were both still significantly shorter with the barbed suture (121.9 minutes and 0.42 days).

There was one intraoperative complication in a patient with the smooth suture, which was unrelated to the suturing. There were no intraoperative complications with the barbed suture.

Postoperative complications among the barbed suture patients included two incision site infections (1.9%), four urinary tract infections (3.7%), one ileus (0.9%), and one blood transfusion (0.9%). In the smooth suture group, there were two UTIs (6.4%). The differences in complication rates were not significant, she noted.

Major Finding: Duration of surgery was significantly shorter with the barbed suture, 117.6 vs. 161.2 minutes for the smooth suture. The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days.

Data Source: Retrospective analysis of 138 consecutive laparoscopic myomectomy cases.

Disclosures: Dr. Cohen said that the study's principal investigator, Dr. Jon I. Einarsson, is a consultant for Ethicon-Endo Surgery. The authors said they have no financial relationship with the device manufacturer, Angiotech Pharmaceuticals.

LAS VEGAS – Use of bidirectional barbed suture reduced operative time by approximately 40 minutes and decreased the length of hospital stay by half a day in a retrospective comparison to use of conventional smooth suture for closure in laparoscopic myomectomy.

Bidirectional barbed suture, in which barbs are cut into the suture so that they are facing in a direction opposite to that of the needle, are designed to resist migration.

The Quill bidirectional barbed suture (Angiotech Pharmaceuticals) has been commercially available in the United States since 2007.

Anecdotally, use of the barbed suture eliminates backsliding of the suture, thereby facilitating myometrial closure, said Dr. Sarah Cohen of Brigham and Women's Hospital, Boston. Dr. Cohen presented the results of the study, which were subsequently published (J. Minim. Invasive Gynecol. 2011;18:92-5).

Perioperative outcomes for a total of 138 consecutive cases of laparoscopic myomectomy performed by a single surgeon were reviewed, including 31 with conventional smooth suture during February 2007 through March 2008 and 107 cases performed from March 2008 through April 2010 using bidirectional barbed suture.

Aside from the suture choice, operative technique was similar for all cases, Dr. Cohen said at the meeting.

There were no significant differences between the two patient groups in demographic characteristics.

The most common indications for undergoing laparoscopic myomectomy were pelvic pain and/or pressure (in 30 smooth and 81 barbed suture patients) and abnormal uterine bleeding (in 11 and 41). The remainder of patients underwent the procedure for other reasons.

The duration of surgery was significantly shorter with the barbed suture, 117.6 minutes compared with 161.2 minutes for the smooth suture.

The length of hospital stay was also significantly reduced, 0.58 vs. 0.97 days. The estimated blood loss, number of myomas removed, and weight of myomas did not differ between the two groups, she reported.

In order to account for any impact of a surgical learning curve, the 31 cases using smooth suture were compared with just the first 31 cases performed after the switch to bidirectional barbed suture. The duration of surgery and the hospital stay were both still significantly shorter with the barbed suture (121.9 minutes and 0.42 days).

There was one intraoperative complication in a patient with the smooth suture, which was unrelated to the suturing. There were no intraoperative complications with the barbed suture.

Postoperative complications among the barbed suture patients included two incision site infections (1.9%), four urinary tract infections (3.7%), one ileus (0.9%), and one blood transfusion (0.9%). In the smooth suture group, there were two UTIs (6.4%). The differences in complication rates were not significant, she noted.

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical examination.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

Physical examination is likely to be normal except for diffuse tenderness and nonspecific neurologic signs (Arthritis Rheum. 2009;60:2839-44).

“This is why, historically, patients with fibromyalgia haven't been believed,” Dr. Clauw commented.

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds (amitriptyline, cyclobenzaprine), serotonin-norepinephrine reuptake inhibitors (milnacipran, duloxetine), gamma hydroxybutyrate, and gabapentin. There is also modest evidence supporting the use of tramadol, selective serotonin reuptake inhibitors, and dopamine agonists (JAMA 2004;292:2388-95).

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical examination.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

Physical examination is likely to be normal except for diffuse tenderness and nonspecific neurologic signs (Arthritis Rheum. 2009;60:2839-44).

“This is why, historically, patients with fibromyalgia haven't been believed,” Dr. Clauw commented.

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds (amitriptyline, cyclobenzaprine), serotonin-norepinephrine reuptake inhibitors (milnacipran, duloxetine), gamma hydroxybutyrate, and gabapentin. There is also modest evidence supporting the use of tramadol, selective serotonin reuptake inhibitors, and dopamine agonists (JAMA 2004;292:2388-95).

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical examination.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

Physical examination is likely to be normal except for diffuse tenderness and nonspecific neurologic signs (Arthritis Rheum. 2009;60:2839-44).

“This is why, historically, patients with fibromyalgia haven't been believed,” Dr. Clauw commented.

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds (amitriptyline, cyclobenzaprine), serotonin-norepinephrine reuptake inhibitors (milnacipran, duloxetine), gamma hydroxybutyrate, and gabapentin. There is also modest evidence supporting the use of tramadol, selective serotonin reuptake inhibitors, and dopamine agonists (JAMA 2004;292:2388-95).

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

BETHESDA, MD. — Evidence-based nonpharmacologic therapies may be at least as effective as medications in treating chronic pain, and the Internet could prove to be a valuable method for delivering these interventions.

Although pharmacologic agents alone are of only modest benefit and rarely lead to clinically meaningful functional improvement among patients with chronic pain, there is strong evidence for nonpharmacologic therapies such as cognitive-behavioral therapy (CBT) in improving functional status and mood, as well as pain itself, David A. Williams, Ph.D., said at the meeting, sponsored by the University of Michigan and the National Institutes of Health.

A meta-analysis of 25 papers found that active psychological treatments based on the principle of CBT produced significantly greater improvements in pain experience, cognitive coping, appraisal, and behavioral expressions of pain, compared with other active treatments, in patients with a variety of chronic pain problems, excluding headache (Pain 1999;80:1-13).

Another meta-analysis, this one including 22 studies of adults with noncancerous chronic low back pain, found that psychological interventions – particularly CBT and self-regulatory treatments – significantly reduced pain intensity, pain-related interference, and depression while significantly improving health-related quality of life. Multidisciplinary approaches that included psychological interventions also had positive effects (Health Psychology 2007;26:1-9).

And two more meta-analyses – one of 49 studies, the other of 23 – have demonstrated an equal or greater effect for nonpharmacologic therapies compared with pharmacologic treatment for fibromyalgia (Ann. Behav. Med. 1999;21: 180-91; Pain 2010;151:280-95).

“There is a 30-year history of nonpharmacologic interventions that have rival effect sizes to some pharmacologic approaches and even surpass some. The problem is, [nonpharmacologic interventions are] rarely used in clinical practice,” explained Dr. Williams, professor of anesthesiology, medicine (rheumatology), psychiatry, and psychology and associate director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

The use of nonpharmacologic treatment has been limited for a variety of reasons.

Medical schools don't spend much time teaching it, insurance companies often don't adequately cover it, patients often can't access it, it lacks the million dollar marketing campaigns that pharmaceutical companies devote to their drugs, and it carries a stigma, he noted.

Delivering such evidence-based interventions via the Internet potentially sidesteps several of the barriers that prevent their wider use, including those of access, cost, convenience, and privacy.

Numerous pilot or small-scale studies have supported the efficacy and utility of this approach, with outcomes that are often consistent with or even greater than those identified when using traditional face-to-face modalities, Dr. Williams said.

The following are studies of Web-based interventions with evidence to support their efficacy. Some of the sites are now online, while others were developed in the context of academic research and are currently not available to the public:

E-Mail Discussion Groups

These early e-health efforts demonstrated significant benefit in a randomized controlled trial of 580 individuals with chronic low back pain, from 49 states. The intervention included a moderated e-mail discussion group combined with a workbook and videotape about back pain. Controls received a subscription to a nonhealth magazine of their choice. At 1 year, the e-mail group had significant improvements in pain, disability, role function, distress, and health care utilization (Arch. Intern. Med. 2002;162:792-6). h

Swedish Study

In this controlled trial, 56 patients with chronic low back pain were randomized to 8 weeks of either Internet-based CBT with telephone support or to a waiting list. Treatment included CBT modules involving relaxation, exercise and stretching, cognitive restructuring, activity pacing, and relapse prevention. Weekly telephone contact with a therapist related to the goals of the program and homework.

At 3 months, those who had treatment showed statistically significant improvements, compared with those on a waiting list, in control over pain, ability to decrease pain, and catastrophizing (Pain 2004;111:368-77).

WEBMAP

This one delivered CBT to the young. In a randomized controlled trial, 48 children aged 11-17 years who had chronic headache, abdominal, or musculoskeletal pain and associated functional disability were assigned with their parents to either an Internet treatment group or to a waiting list.

The Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions, in separate sites for patients and parents.

Controls had only current medical care (Pain 2009;146:205-13).

There was a significantly greater reduction in activity limitations and pain intensity at post treatment for the Internet treatment group, which were maintained at a 3-month follow-up. Clinically significant lessening of pain was also greater for the Internet treatment group than for the waiting-list control group.

Teens Taking Charge

Another CBT-based site for young people, “Teens Taking Charge: Managing Arthritis Online” focuses specifically on those with juvenile idiopathic arthritis and their parents.

In a 12-week nonblinded, randomized controlled trial done at four centers in Canada, 46 adolescents aged 12-18 with JIA plus one parent each were randomized to the Internet intervention or control arm (J. Rheumatol. 2010;37:1944-52).

The CBT-based self-management modules, written specifically for teens, provide education about arthritis and symptom management, and also address areas such as relaxation, medications, distraction, and managing thoughts. A journal page allows the teen to track progress. Two modules for parents focus on arthritis impact and “letting go.” Multimedia components include more than 300 pages of content, including Flash animation, video, forums for teens and parents, surveys, and weekly quizzes. The online “coach” has a BA degree in psychology.

At posttreatment, the intervention group had significantly better knowledge and lower average weekly pain intensity.

painAction

This interactive self-management Web site for people with chronic back pain was evaluated in a pretest-posttest controlled trial in which 209 patients were randomized to either the site (

www.painaction.com

The site was based on CBT and self-management principles, including collaborative decision making, goal setting, problem solving, relapse prevention, nutrition, stress management, and exercise. As with many of the other sites, this one included interactive tools, personalized assessments, and a library of articles.

At 6 months, clinically significant changes were seen in pain, depression, anxiety, and global ratings of improvement among those randomized to the site, which is supported by Endo Pharmaceuticals Inc. and King Pharmaceuticals Inc.

Living Well With Fibromyalgia

From Dr. Williams' group at the University of Michigan, this Internet-based exercise and behavioral self-management program for fibromyalgia was designed for use in the context of clinical care. A total of 118 patients were randomized to the program plus standard care, or standard care alone (Pain 2010;151:694-702).

Among the site's features are CBT modules including educational material about fibromyalgia and its treatment; symptom management with modalities including medications, exercise, sleep, and relaxation; and lifestyle changes including goal setting, problem solving, and graded activation.

Multimedia tools include video lectures by professionals, downloadable worksheets, self-monitoring forms, and audio recordings of exercises (

www.fibroguide.com

At 6 months, overall improvement was seen in 57% with the Web program vs. 21% with standard care alone.

The proportion experiencing 30% pain improvement or greater (pain responders) was 29% vs. 8% with standard care alone, and functional improvement, defined as an improvement of 0.5 standard deviations, was seen in 31% vs. 6%. All differences were statistically significant, and the number needed to treat for both outcomes was 5, better than the typical 7-19 seen in pharmaceutical trials, Dr. Williams noted.

In a recent meta-analysis of 11 studies of Web-based interventions for chronic pain that used pain scale scores as the main outcome, the standardized mean difference between intervention and waiting-list group means was 0.285, favoring the Web interventions but with a small effect size (J. Pain 2010;11:917-29).

“Broader adoption of this method of delivering care for pain needs to be moved to the next level in terms of both infrastructure and practitioner consensus,” Dr. Williams said in an interview.

“Hopes of expanding Internet-based behavioral treatment for pain would need to contain content reflecting a broader consensus of experts from the various disciplines associated with pain management,” he said.

“Currently there is great interest in developing such resources both in the public and private sectors.

“This appears to be a valuable approach to supplying individuals with an aspect of effective pain management that is often missing.”

Dr. Williams is a consultant for Eli Lilly & Co., Forest Pharmaceuticals, and Bristol-Myers Squibb.

BETHESDA, MD. — Evidence-based nonpharmacologic therapies may be at least as effective as medications in treating chronic pain, and the Internet could prove to be a valuable method for delivering these interventions.

Although pharmacologic agents alone are of only modest benefit and rarely lead to clinically meaningful functional improvement among patients with chronic pain, there is strong evidence for nonpharmacologic therapies such as cognitive-behavioral therapy (CBT) in improving functional status and mood, as well as pain itself, David A. Williams, Ph.D., said at the meeting, sponsored by the University of Michigan and the National Institutes of Health.

A meta-analysis of 25 papers found that active psychological treatments based on the principle of CBT produced significantly greater improvements in pain experience, cognitive coping, appraisal, and behavioral expressions of pain, compared with other active treatments, in patients with a variety of chronic pain problems, excluding headache (Pain 1999;80:1-13).

Another meta-analysis, this one including 22 studies of adults with noncancerous chronic low back pain, found that psychological interventions – particularly CBT and self-regulatory treatments – significantly reduced pain intensity, pain-related interference, and depression while significantly improving health-related quality of life. Multidisciplinary approaches that included psychological interventions also had positive effects (Health Psychology 2007;26:1-9).

And two more meta-analyses – one of 49 studies, the other of 23 – have demonstrated an equal or greater effect for nonpharmacologic therapies compared with pharmacologic treatment for fibromyalgia (Ann. Behav. Med. 1999;21: 180-91; Pain 2010;151:280-95).

“There is a 30-year history of nonpharmacologic interventions that have rival effect sizes to some pharmacologic approaches and even surpass some. The problem is, [nonpharmacologic interventions are] rarely used in clinical practice,” explained Dr. Williams, professor of anesthesiology, medicine (rheumatology), psychiatry, and psychology and associate director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

The use of nonpharmacologic treatment has been limited for a variety of reasons.

Medical schools don't spend much time teaching it, insurance companies often don't adequately cover it, patients often can't access it, it lacks the million dollar marketing campaigns that pharmaceutical companies devote to their drugs, and it carries a stigma, he noted.

Delivering such evidence-based interventions via the Internet potentially sidesteps several of the barriers that prevent their wider use, including those of access, cost, convenience, and privacy.

Numerous pilot or small-scale studies have supported the efficacy and utility of this approach, with outcomes that are often consistent with or even greater than those identified when using traditional face-to-face modalities, Dr. Williams said.

The following are studies of Web-based interventions with evidence to support their efficacy. Some of the sites are now online, while others were developed in the context of academic research and are currently not available to the public:

E-Mail Discussion Groups

These early e-health efforts demonstrated significant benefit in a randomized controlled trial of 580 individuals with chronic low back pain, from 49 states. The intervention included a moderated e-mail discussion group combined with a workbook and videotape about back pain. Controls received a subscription to a nonhealth magazine of their choice. At 1 year, the e-mail group had significant improvements in pain, disability, role function, distress, and health care utilization (Arch. Intern. Med. 2002;162:792-6). h

Swedish Study

In this controlled trial, 56 patients with chronic low back pain were randomized to 8 weeks of either Internet-based CBT with telephone support or to a waiting list. Treatment included CBT modules involving relaxation, exercise and stretching, cognitive restructuring, activity pacing, and relapse prevention. Weekly telephone contact with a therapist related to the goals of the program and homework.

At 3 months, those who had treatment showed statistically significant improvements, compared with those on a waiting list, in control over pain, ability to decrease pain, and catastrophizing (Pain 2004;111:368-77).

WEBMAP

This one delivered CBT to the young. In a randomized controlled trial, 48 children aged 11-17 years who had chronic headache, abdominal, or musculoskeletal pain and associated functional disability were assigned with their parents to either an Internet treatment group or to a waiting list.

The Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions, in separate sites for patients and parents.

Controls had only current medical care (Pain 2009;146:205-13).

There was a significantly greater reduction in activity limitations and pain intensity at post treatment for the Internet treatment group, which were maintained at a 3-month follow-up. Clinically significant lessening of pain was also greater for the Internet treatment group than for the waiting-list control group.

Teens Taking Charge

Another CBT-based site for young people, “Teens Taking Charge: Managing Arthritis Online” focuses specifically on those with juvenile idiopathic arthritis and their parents.

In a 12-week nonblinded, randomized controlled trial done at four centers in Canada, 46 adolescents aged 12-18 with JIA plus one parent each were randomized to the Internet intervention or control arm (J. Rheumatol. 2010;37:1944-52).

The CBT-based self-management modules, written specifically for teens, provide education about arthritis and symptom management, and also address areas such as relaxation, medications, distraction, and managing thoughts. A journal page allows the teen to track progress. Two modules for parents focus on arthritis impact and “letting go.” Multimedia components include more than 300 pages of content, including Flash animation, video, forums for teens and parents, surveys, and weekly quizzes. The online “coach” has a BA degree in psychology.

At posttreatment, the intervention group had significantly better knowledge and lower average weekly pain intensity.

painAction

This interactive self-management Web site for people with chronic back pain was evaluated in a pretest-posttest controlled trial in which 209 patients were randomized to either the site (

www.painaction.com

The site was based on CBT and self-management principles, including collaborative decision making, goal setting, problem solving, relapse prevention, nutrition, stress management, and exercise. As with many of the other sites, this one included interactive tools, personalized assessments, and a library of articles.

At 6 months, clinically significant changes were seen in pain, depression, anxiety, and global ratings of improvement among those randomized to the site, which is supported by Endo Pharmaceuticals Inc. and King Pharmaceuticals Inc.

Living Well With Fibromyalgia

From Dr. Williams' group at the University of Michigan, this Internet-based exercise and behavioral self-management program for fibromyalgia was designed for use in the context of clinical care. A total of 118 patients were randomized to the program plus standard care, or standard care alone (Pain 2010;151:694-702).

Among the site's features are CBT modules including educational material about fibromyalgia and its treatment; symptom management with modalities including medications, exercise, sleep, and relaxation; and lifestyle changes including goal setting, problem solving, and graded activation.

Multimedia tools include video lectures by professionals, downloadable worksheets, self-monitoring forms, and audio recordings of exercises (

www.fibroguide.com

At 6 months, overall improvement was seen in 57% with the Web program vs. 21% with standard care alone.

The proportion experiencing 30% pain improvement or greater (pain responders) was 29% vs. 8% with standard care alone, and functional improvement, defined as an improvement of 0.5 standard deviations, was seen in 31% vs. 6%. All differences were statistically significant, and the number needed to treat for both outcomes was 5, better than the typical 7-19 seen in pharmaceutical trials, Dr. Williams noted.

In a recent meta-analysis of 11 studies of Web-based interventions for chronic pain that used pain scale scores as the main outcome, the standardized mean difference between intervention and waiting-list group means was 0.285, favoring the Web interventions but with a small effect size (J. Pain 2010;11:917-29).

“Broader adoption of this method of delivering care for pain needs to be moved to the next level in terms of both infrastructure and practitioner consensus,” Dr. Williams said in an interview.

“Hopes of expanding Internet-based behavioral treatment for pain would need to contain content reflecting a broader consensus of experts from the various disciplines associated with pain management,” he said.

“Currently there is great interest in developing such resources both in the public and private sectors.

“This appears to be a valuable approach to supplying individuals with an aspect of effective pain management that is often missing.”

Dr. Williams is a consultant for Eli Lilly & Co., Forest Pharmaceuticals, and Bristol-Myers Squibb.

BETHESDA, MD. — Evidence-based nonpharmacologic therapies may be at least as effective as medications in treating chronic pain, and the Internet could prove to be a valuable method for delivering these interventions.

Although pharmacologic agents alone are of only modest benefit and rarely lead to clinically meaningful functional improvement among patients with chronic pain, there is strong evidence for nonpharmacologic therapies such as cognitive-behavioral therapy (CBT) in improving functional status and mood, as well as pain itself, David A. Williams, Ph.D., said at the meeting, sponsored by the University of Michigan and the National Institutes of Health.

A meta-analysis of 25 papers found that active psychological treatments based on the principle of CBT produced significantly greater improvements in pain experience, cognitive coping, appraisal, and behavioral expressions of pain, compared with other active treatments, in patients with a variety of chronic pain problems, excluding headache (Pain 1999;80:1-13).

Another meta-analysis, this one including 22 studies of adults with noncancerous chronic low back pain, found that psychological interventions – particularly CBT and self-regulatory treatments – significantly reduced pain intensity, pain-related interference, and depression while significantly improving health-related quality of life. Multidisciplinary approaches that included psychological interventions also had positive effects (Health Psychology 2007;26:1-9).

And two more meta-analyses – one of 49 studies, the other of 23 – have demonstrated an equal or greater effect for nonpharmacologic therapies compared with pharmacologic treatment for fibromyalgia (Ann. Behav. Med. 1999;21: 180-91; Pain 2010;151:280-95).

“There is a 30-year history of nonpharmacologic interventions that have rival effect sizes to some pharmacologic approaches and even surpass some. The problem is, [nonpharmacologic interventions are] rarely used in clinical practice,” explained Dr. Williams, professor of anesthesiology, medicine (rheumatology), psychiatry, and psychology and associate director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

The use of nonpharmacologic treatment has been limited for a variety of reasons.

Medical schools don't spend much time teaching it, insurance companies often don't adequately cover it, patients often can't access it, it lacks the million dollar marketing campaigns that pharmaceutical companies devote to their drugs, and it carries a stigma, he noted.

Delivering such evidence-based interventions via the Internet potentially sidesteps several of the barriers that prevent their wider use, including those of access, cost, convenience, and privacy.

Numerous pilot or small-scale studies have supported the efficacy and utility of this approach, with outcomes that are often consistent with or even greater than those identified when using traditional face-to-face modalities, Dr. Williams said.

The following are studies of Web-based interventions with evidence to support their efficacy. Some of the sites are now online, while others were developed in the context of academic research and are currently not available to the public:

E-Mail Discussion Groups

These early e-health efforts demonstrated significant benefit in a randomized controlled trial of 580 individuals with chronic low back pain, from 49 states. The intervention included a moderated e-mail discussion group combined with a workbook and videotape about back pain. Controls received a subscription to a nonhealth magazine of their choice. At 1 year, the e-mail group had significant improvements in pain, disability, role function, distress, and health care utilization (Arch. Intern. Med. 2002;162:792-6). h

Swedish Study

In this controlled trial, 56 patients with chronic low back pain were randomized to 8 weeks of either Internet-based CBT with telephone support or to a waiting list. Treatment included CBT modules involving relaxation, exercise and stretching, cognitive restructuring, activity pacing, and relapse prevention. Weekly telephone contact with a therapist related to the goals of the program and homework.

At 3 months, those who had treatment showed statistically significant improvements, compared with those on a waiting list, in control over pain, ability to decrease pain, and catastrophizing (Pain 2004;111:368-77).

WEBMAP

This one delivered CBT to the young. In a randomized controlled trial, 48 children aged 11-17 years who had chronic headache, abdominal, or musculoskeletal pain and associated functional disability were assigned with their parents to either an Internet treatment group or to a waiting list.

The Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions, in separate sites for patients and parents.

Controls had only current medical care (Pain 2009;146:205-13).

There was a significantly greater reduction in activity limitations and pain intensity at post treatment for the Internet treatment group, which were maintained at a 3-month follow-up. Clinically significant lessening of pain was also greater for the Internet treatment group than for the waiting-list control group.

Teens Taking Charge

Another CBT-based site for young people, “Teens Taking Charge: Managing Arthritis Online” focuses specifically on those with juvenile idiopathic arthritis and their parents.

In a 12-week nonblinded, randomized controlled trial done at four centers in Canada, 46 adolescents aged 12-18 with JIA plus one parent each were randomized to the Internet intervention or control arm (J. Rheumatol. 2010;37:1944-52).

The CBT-based self-management modules, written specifically for teens, provide education about arthritis and symptom management, and also address areas such as relaxation, medications, distraction, and managing thoughts. A journal page allows the teen to track progress. Two modules for parents focus on arthritis impact and “letting go.” Multimedia components include more than 300 pages of content, including Flash animation, video, forums for teens and parents, surveys, and weekly quizzes. The online “coach” has a BA degree in psychology.

At posttreatment, the intervention group had significantly better knowledge and lower average weekly pain intensity.

painAction

This interactive self-management Web site for people with chronic back pain was evaluated in a pretest-posttest controlled trial in which 209 patients were randomized to either the site (

www.painaction.com

The site was based on CBT and self-management principles, including collaborative decision making, goal setting, problem solving, relapse prevention, nutrition, stress management, and exercise. As with many of the other sites, this one included interactive tools, personalized assessments, and a library of articles.

At 6 months, clinically significant changes were seen in pain, depression, anxiety, and global ratings of improvement among those randomized to the site, which is supported by Endo Pharmaceuticals Inc. and King Pharmaceuticals Inc.

Living Well With Fibromyalgia

From Dr. Williams' group at the University of Michigan, this Internet-based exercise and behavioral self-management program for fibromyalgia was designed for use in the context of clinical care. A total of 118 patients were randomized to the program plus standard care, or standard care alone (Pain 2010;151:694-702).

Among the site's features are CBT modules including educational material about fibromyalgia and its treatment; symptom management with modalities including medications, exercise, sleep, and relaxation; and lifestyle changes including goal setting, problem solving, and graded activation.

Multimedia tools include video lectures by professionals, downloadable worksheets, self-monitoring forms, and audio recordings of exercises (

www.fibroguide.com

At 6 months, overall improvement was seen in 57% with the Web program vs. 21% with standard care alone.

The proportion experiencing 30% pain improvement or greater (pain responders) was 29% vs. 8% with standard care alone, and functional improvement, defined as an improvement of 0.5 standard deviations, was seen in 31% vs. 6%. All differences were statistically significant, and the number needed to treat for both outcomes was 5, better than the typical 7-19 seen in pharmaceutical trials, Dr. Williams noted.

In a recent meta-analysis of 11 studies of Web-based interventions for chronic pain that used pain scale scores as the main outcome, the standardized mean difference between intervention and waiting-list group means was 0.285, favoring the Web interventions but with a small effect size (J. Pain 2010;11:917-29).

“Broader adoption of this method of delivering care for pain needs to be moved to the next level in terms of both infrastructure and practitioner consensus,” Dr. Williams said in an interview.

“Hopes of expanding Internet-based behavioral treatment for pain would need to contain content reflecting a broader consensus of experts from the various disciplines associated with pain management,” he said.

“Currently there is great interest in developing such resources both in the public and private sectors.

“This appears to be a valuable approach to supplying individuals with an aspect of effective pain management that is often missing.”

Dr. Williams is a consultant for Eli Lilly & Co., Forest Pharmaceuticals, and Bristol-Myers Squibb.

Each year, the Advisory Committee on Immunization Practices (ACIP) publishes immunization schedules for persons aged 0 through 18 years. For 2011, most of the changes from 2010 are in the footnotes, with only small changes to the grid itself.

Among the new items:

▸ Hepatitis B vaccine. Guidance has been added to the hepatitis B vaccine schedule for children who did not receive the recommended birth dose. They should receive three doses on a schedule of 0, 1, and 6 months, with the final dose in the series administered no earlier than age 24 weeks.

▸ 13-Valent pneumococcal conjugate vaccine. Information on use of the new 13-valent pneumococcal conjugate vaccine (PCV13) has been added. Prevnar-13 was licensed in February 2010 and recommended by ACIP to replace the old 7-valent version for routine childhood immunization. Children who began the series with PCV7 should receive the rest of the doses in the series as PCV13.

Children aged 14–59 months and those aged 60–71 months with underlying medical conditions who received the entire age-appropriate series of PCV7 should receive one supplemental dose of PCV13. That dose should be given at least 8 weeks after the previous PCV7 dose.

▸ Influenza vaccine. Guidance has been added for administration of one or two doses of seasonal influenza vaccine based upon the child's history of monovalent 2009 H1N1 vaccination. Two doses – separated by at least 4 weeks – should be given to children aged 6 months through 8 years who are receiving seasonal influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but received only one dose.

Children aged 6 months through 8 years who received no doses of monovalent 2009 H1N1 vaccine should receive two doses of 2010–2011 seasonal influenza vaccine, which contains H1N1.

▸ Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. Use of Tdap among children aged 7–10 years who are incompletely vaccinated against pertussis – either never vaccinated or with unknown status – is now addressed, with a recommendation that those children receive a single dose of Tdap. Reference to a specified interval between tetanus and between tetanus and diphtheria toxoids (Td) and Tdap vaccination has been removed, so Tdap can be administered without regard for the interval since the last dose of Td (or T).

▸ Meningococcal conjugate vaccine, quadrivalent (MCV4). For MCV4, recommendations for a routine two-dose schedule have been added for certain individuals at high risk of meningococcal disease, including children aged 2–10 years with persistent complement-component deficiency and anatomic or functional asplenia (who should also receive one dose every 5 years thereafter) and those with HIV infection.

A new recommendation for a booster dose of MCV4 at age 16 years also has been added.

▸ Human papillomavirus vaccine (HPV) and Haemophilus influenzae type b (Hib). Footnote sections on use of the HPV vaccine and use of the Hib vaccine in persons aged 5 years and older in the catch-up schedule have been condensed.

Detailed recommendations for using vaccines are available from ACIP statements (available at www.cdc.gov/vaccines/pubs/acip-list.htmwww.vaers.hhs.gov)

Each year, the Advisory Committee on Immunization Practices (ACIP) publishes immunization schedules for persons aged 0 through 18 years. For 2011, most of the changes from 2010 are in the footnotes, with only small changes to the grid itself.

Among the new items:

▸ Hepatitis B vaccine. Guidance has been added to the hepatitis B vaccine schedule for children who did not receive the recommended birth dose. They should receive three doses on a schedule of 0, 1, and 6 months, with the final dose in the series administered no earlier than age 24 weeks.

▸ 13-Valent pneumococcal conjugate vaccine. Information on use of the new 13-valent pneumococcal conjugate vaccine (PCV13) has been added. Prevnar-13 was licensed in February 2010 and recommended by ACIP to replace the old 7-valent version for routine childhood immunization. Children who began the series with PCV7 should receive the rest of the doses in the series as PCV13.

Children aged 14–59 months and those aged 60–71 months with underlying medical conditions who received the entire age-appropriate series of PCV7 should receive one supplemental dose of PCV13. That dose should be given at least 8 weeks after the previous PCV7 dose.

▸ Influenza vaccine. Guidance has been added for administration of one or two doses of seasonal influenza vaccine based upon the child's history of monovalent 2009 H1N1 vaccination. Two doses – separated by at least 4 weeks – should be given to children aged 6 months through 8 years who are receiving seasonal influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but received only one dose.

Children aged 6 months through 8 years who received no doses of monovalent 2009 H1N1 vaccine should receive two doses of 2010–2011 seasonal influenza vaccine, which contains H1N1.

▸ Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. Use of Tdap among children aged 7–10 years who are incompletely vaccinated against pertussis – either never vaccinated or with unknown status – is now addressed, with a recommendation that those children receive a single dose of Tdap. Reference to a specified interval between tetanus and between tetanus and diphtheria toxoids (Td) and Tdap vaccination has been removed, so Tdap can be administered without regard for the interval since the last dose of Td (or T).

▸ Meningococcal conjugate vaccine, quadrivalent (MCV4). For MCV4, recommendations for a routine two-dose schedule have been added for certain individuals at high risk of meningococcal disease, including children aged 2–10 years with persistent complement-component deficiency and anatomic or functional asplenia (who should also receive one dose every 5 years thereafter) and those with HIV infection.

A new recommendation for a booster dose of MCV4 at age 16 years also has been added.

▸ Human papillomavirus vaccine (HPV) and Haemophilus influenzae type b (Hib). Footnote sections on use of the HPV vaccine and use of the Hib vaccine in persons aged 5 years and older in the catch-up schedule have been condensed.

Detailed recommendations for using vaccines are available from ACIP statements (available at www.cdc.gov/vaccines/pubs/acip-list.htmwww.vaers.hhs.gov)

Each year, the Advisory Committee on Immunization Practices (ACIP) publishes immunization schedules for persons aged 0 through 18 years. For 2011, most of the changes from 2010 are in the footnotes, with only small changes to the grid itself.

Among the new items:

▸ Hepatitis B vaccine. Guidance has been added to the hepatitis B vaccine schedule for children who did not receive the recommended birth dose. They should receive three doses on a schedule of 0, 1, and 6 months, with the final dose in the series administered no earlier than age 24 weeks.

▸ 13-Valent pneumococcal conjugate vaccine. Information on use of the new 13-valent pneumococcal conjugate vaccine (PCV13) has been added. Prevnar-13 was licensed in February 2010 and recommended by ACIP to replace the old 7-valent version for routine childhood immunization. Children who began the series with PCV7 should receive the rest of the doses in the series as PCV13.

Children aged 14–59 months and those aged 60–71 months with underlying medical conditions who received the entire age-appropriate series of PCV7 should receive one supplemental dose of PCV13. That dose should be given at least 8 weeks after the previous PCV7 dose.

▸ Influenza vaccine. Guidance has been added for administration of one or two doses of seasonal influenza vaccine based upon the child's history of monovalent 2009 H1N1 vaccination. Two doses – separated by at least 4 weeks – should be given to children aged 6 months through 8 years who are receiving seasonal influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but received only one dose.

Children aged 6 months through 8 years who received no doses of monovalent 2009 H1N1 vaccine should receive two doses of 2010–2011 seasonal influenza vaccine, which contains H1N1.

▸ Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. Use of Tdap among children aged 7–10 years who are incompletely vaccinated against pertussis – either never vaccinated or with unknown status – is now addressed, with a recommendation that those children receive a single dose of Tdap. Reference to a specified interval between tetanus and between tetanus and diphtheria toxoids (Td) and Tdap vaccination has been removed, so Tdap can be administered without regard for the interval since the last dose of Td (or T).

▸ Meningococcal conjugate vaccine, quadrivalent (MCV4). For MCV4, recommendations for a routine two-dose schedule have been added for certain individuals at high risk of meningococcal disease, including children aged 2–10 years with persistent complement-component deficiency and anatomic or functional asplenia (who should also receive one dose every 5 years thereafter) and those with HIV infection.

A new recommendation for a booster dose of MCV4 at age 16 years also has been added.

▸ Human papillomavirus vaccine (HPV) and Haemophilus influenzae type b (Hib). Footnote sections on use of the HPV vaccine and use of the Hib vaccine in persons aged 5 years and older in the catch-up schedule have been condensed.

Detailed recommendations for using vaccines are available from ACIP statements (available at www.cdc.gov/vaccines/pubs/acip-list.htmwww.vaers.hhs.gov)

LAS VEGAS – Although women who had more severe stress urinary incontinence were more likely to require repeat injections, they were also more likely to respond to transurethral bulking agent injection therapy, results of a retrospective study of 124 cases showed.

“Clinical and urodynamic parameters may help predict treatment response and the likelihood of retreatment, such that patients with indicators of more severe incontinence have a significantly better treatment response, although they may require repeat injections to achieve this result,” said Dr. Deborah R. Karp of the Cleveland Clinic Florida in Weston, who presented the results at the meeting.

The patients all underwent transurethral bulking with Uroplasty's Macroplastique (MPQ) between July 2007 and September 2009. They had a mean age of 74 years and a mean body mass index of 28 kg/m

A self-report incontinence severity scale was used, in which 0 was complete continence, 1 indicated one or two incontinent episodes per day, 2 indicated three or four episodes per day, and 3 indicated more than five episodes per day. Treatment response (defined as a decrease by at least 1 point on the incontinence severity score) was reported by 61% (76) of the women, whereas the other 39% (48) reported treatment failure (defined as either no change or an increase in the score).

Of the 76 responders, 66% (50) were treated with a single injection, whereas the rest (26) required multiple injections to achieve a response. The strongest variable associated with a positive treatment response was previous anterior colporrhaphy (odds ratio, 2.8). Other significant predictors included a maximum urethral closure pressure (MUCP) of less than or equal to 40 cm H₂O (OR, 2.6), clinical reporting of mixed incontinence (OR, 2.4), use of three or more pads per day (OR, 2.1), five or more incontinent episodes per day (OR, 2.1), or a first leak of less than 50 mL on cystometrogram (OR, 2.0).

Factors found not to be associated with treatment response included urethral hypermobility, Valsalva leak point pressure (VLPP), previous sling, and the volume of MPQ injected, Dr. Karp reported.

A secondary analysis examined the combined group of 26 responders and 16 nonresponders who received repeat injections. Variables associated with the need for repeat treatment included indicators of more severe incontinence, including leak point pressure of 60 cm H₂O or lower (OR, 7.3), history of urethrolysis (OR, 6.2), low MUCP (OR, 3.5), VLPP of 60 cm H₂O or lower (OR, 3.5), five or more incontinent episodes per day (OR, 3.0), and a positive empty supine test (OR, 2.7).

Dr. Karp stated that she had no disclosures. The study's principal investigator, Dr. G. Willy Davila, is a consultant for and has received honoraria from Astellas Pharma US, Watson Pharmaceuticals, American Medical Systems, Novasys Medical, and CL Medical. He has also received research funding from American Medical Systems and Astellas Pharma US. He does not have a financial relationship with Uroplasty.

LAS VEGAS – Although women who had more severe stress urinary incontinence were more likely to require repeat injections, they were also more likely to respond to transurethral bulking agent injection therapy, results of a retrospective study of 124 cases showed.

“Clinical and urodynamic parameters may help predict treatment response and the likelihood of retreatment, such that patients with indicators of more severe incontinence have a significantly better treatment response, although they may require repeat injections to achieve this result,” said Dr. Deborah R. Karp of the Cleveland Clinic Florida in Weston, who presented the results at the meeting.

The patients all underwent transurethral bulking with Uroplasty's Macroplastique (MPQ) between July 2007 and September 2009. They had a mean age of 74 years and a mean body mass index of 28 kg/m

A self-report incontinence severity scale was used, in which 0 was complete continence, 1 indicated one or two incontinent episodes per day, 2 indicated three or four episodes per day, and 3 indicated more than five episodes per day. Treatment response (defined as a decrease by at least 1 point on the incontinence severity score) was reported by 61% (76) of the women, whereas the other 39% (48) reported treatment failure (defined as either no change or an increase in the score).

Of the 76 responders, 66% (50) were treated with a single injection, whereas the rest (26) required multiple injections to achieve a response. The strongest variable associated with a positive treatment response was previous anterior colporrhaphy (odds ratio, 2.8). Other significant predictors included a maximum urethral closure pressure (MUCP) of less than or equal to 40 cm H₂O (OR, 2.6), clinical reporting of mixed incontinence (OR, 2.4), use of three or more pads per day (OR, 2.1), five or more incontinent episodes per day (OR, 2.1), or a first leak of less than 50 mL on cystometrogram (OR, 2.0).

Factors found not to be associated with treatment response included urethral hypermobility, Valsalva leak point pressure (VLPP), previous sling, and the volume of MPQ injected, Dr. Karp reported.

A secondary analysis examined the combined group of 26 responders and 16 nonresponders who received repeat injections. Variables associated with the need for repeat treatment included indicators of more severe incontinence, including leak point pressure of 60 cm H₂O or lower (OR, 7.3), history of urethrolysis (OR, 6.2), low MUCP (OR, 3.5), VLPP of 60 cm H₂O or lower (OR, 3.5), five or more incontinent episodes per day (OR, 3.0), and a positive empty supine test (OR, 2.7).

Dr. Karp stated that she had no disclosures. The study's principal investigator, Dr. G. Willy Davila, is a consultant for and has received honoraria from Astellas Pharma US, Watson Pharmaceuticals, American Medical Systems, Novasys Medical, and CL Medical. He has also received research funding from American Medical Systems and Astellas Pharma US. He does not have a financial relationship with Uroplasty.

LAS VEGAS – Although women who had more severe stress urinary incontinence were more likely to require repeat injections, they were also more likely to respond to transurethral bulking agent injection therapy, results of a retrospective study of 124 cases showed.

“Clinical and urodynamic parameters may help predict treatment response and the likelihood of retreatment, such that patients with indicators of more severe incontinence have a significantly better treatment response, although they may require repeat injections to achieve this result,” said Dr. Deborah R. Karp of the Cleveland Clinic Florida in Weston, who presented the results at the meeting.

The patients all underwent transurethral bulking with Uroplasty's Macroplastique (MPQ) between July 2007 and September 2009. They had a mean age of 74 years and a mean body mass index of 28 kg/m

A self-report incontinence severity scale was used, in which 0 was complete continence, 1 indicated one or two incontinent episodes per day, 2 indicated three or four episodes per day, and 3 indicated more than five episodes per day. Treatment response (defined as a decrease by at least 1 point on the incontinence severity score) was reported by 61% (76) of the women, whereas the other 39% (48) reported treatment failure (defined as either no change or an increase in the score).

Of the 76 responders, 66% (50) were treated with a single injection, whereas the rest (26) required multiple injections to achieve a response. The strongest variable associated with a positive treatment response was previous anterior colporrhaphy (odds ratio, 2.8). Other significant predictors included a maximum urethral closure pressure (MUCP) of less than or equal to 40 cm H₂O (OR, 2.6), clinical reporting of mixed incontinence (OR, 2.4), use of three or more pads per day (OR, 2.1), five or more incontinent episodes per day (OR, 2.1), or a first leak of less than 50 mL on cystometrogram (OR, 2.0).

Factors found not to be associated with treatment response included urethral hypermobility, Valsalva leak point pressure (VLPP), previous sling, and the volume of MPQ injected, Dr. Karp reported.

A secondary analysis examined the combined group of 26 responders and 16 nonresponders who received repeat injections. Variables associated with the need for repeat treatment included indicators of more severe incontinence, including leak point pressure of 60 cm H₂O or lower (OR, 7.3), history of urethrolysis (OR, 6.2), low MUCP (OR, 3.5), VLPP of 60 cm H₂O or lower (OR, 3.5), five or more incontinent episodes per day (OR, 3.0), and a positive empty supine test (OR, 2.7).

Dr. Karp stated that she had no disclosures. The study's principal investigator, Dr. G. Willy Davila, is a consultant for and has received honoraria from Astellas Pharma US, Watson Pharmaceuticals, American Medical Systems, Novasys Medical, and CL Medical. He has also received research funding from American Medical Systems and Astellas Pharma US. He does not have a financial relationship with Uroplasty.

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical exam.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, gamma hydroxybutyrate, and gabapentin.

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical exam.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, gamma hydroxybutyrate, and gabapentin.

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

BETHESDA, MD. – When it comes to managing chronic pain, Dr. Daniel J. Clauw said physicians have been looking in the wrong places.

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” said Dr. Clauw, director of the chronic pain and fatigue research center at the University of Michigan, Ann Arbor.

Historically, it has been assumed that when there was a disparity between peripheral findings and pain, psychological factors were at work. But the current view of chronic pain is that while it may originate from peripheral nociceptive input or nerve damage, central neuronal factors – at least some of them genetically determined – are nearly always playing a role in leading to interindividual differences in pain sensitivity, which are in turn closely associated with clinical outcomes.

For instance, population-based studies have shown that 30%-40% of individuals with radiographic evidence of severe damage from osteoarthritis are pain free, while 10% of those with normal radiographs have severe pain (Br. J. Rheumatol. 1997;36:726-8). Psychological factors explain very little of the variance between symptoms and structure (Arthritis Care Res. 1998;11:60-5), suggesting that central mechanisms involved in pain processing are at work, Dr. Clauw said at the workshop, sponsored by the University of Michigan and the National Institutes of Health.

Of course, individuals with osteoarthritis and rheumatoid arthritis will often have evidence of nociceptive input, while those with fibromyalgia have more prominent central factors. But no chronic pain state is solely due to any one of these mechanisms, he said.

“The scientific paradigm shift requires that we rethink everything from diagnostics and treatment approaches – which currently place an unjustified importance on treating peripheral factors,” he said.

The new paradigm suggests that, regardless of the specific diagnosis, “central pain states” including fibromyalgia, rheumatoid arthritis, osteoarthritis, lupus, and low back pain all tend to share certain characteristics that can be better assessed by asking questions than by physical exam.

Showing patients a body diagram and asking them to label all the areas where they have pain is a simple assessment tool for multifocal pain. Also, ask about previous pain and other somatic symptoms such as fatigue, memory difficulty, mood disorders, and sleep disturbances, all common in the context of central pain but not with pain that is solely peripheral.

Is the pain triggered or exacerbated by stressors, such as psychological stress, infections, or physical trauma? Was there a salient stressor in the patient's early life, such as an auto accident or the death of a loved one? All are common among patients with central pain, said Dr. Clauw, professor of anesthesiology and medicine (rheumatology) at the university.

Because these patients tend to have global sensory processing problems, asking about hypersensitivity to bright lights, odors, or noises will also help confirm the “central” diagnosis. Take a family history of pain as well, as there are strong familial and genetic linkages among the chronic pain syndromes, at least among women (Psychol. Med. 2009;39:497-505).

As for treatment, it is becoming increasingly clear that peripherally acting pharmacologic agents such as opioids, corticosteroids, and nonsteroidal anti-inflammatory drugs simply do not work in central pain states.

Far more effective for fibromyalgia – and most likely other central pain states as well – are dual reuptake inhibitors such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, gamma hydroxybutyrate, and gabapentin.

Nonpharmacologic therapies are also beneficial, including cognitive-behavioral therapy, exercise, and sleep hygiene (Best Pract. Res. Clin. Rheumatol. 2003;17:685-701).

Dr. Clauw disclosed that he is a consultant for Pfizer, Forest, Eli Lilly, Pierre Fabre Laboratories, Cypress Biosciences, Wyeth, UCB, AstraZeneca, Merck, Johnson & Johnson, Nuvo, and Jazz. He said he has also received research support from Pfizer, Cypress, and Forest.

'What we see in the peripheral tissues is not necessarily what our patients are experiencing' in terms of pain.

Source DR. CLAUW

PITTSBURGH – Emerging evidence is leading to optimism that early interventions could prevent the onset of schizophrenia or reduce its impact on cognitive function.

Among psychiatric disorders, schizophrenia tends to manifest later in life than most, typically not until late adolescence or early adulthood. Yet, evidence suggests that brain changes actually occur much earlier in life among those destined to develop the disease, said Dr. Matcheri S. Keshavan, the Stanley Cobb Professor of Psychiatry at Harvard Medical School and vice chair of public psychiatry at Beth Israel Deaconess Medical Center and the Massachusetts Mental Health Center, all in Boston.

Indeed, schizophrenia is increasingly being viewed as a neurodevelopmental disorder with psychosis as a late and potentially preventable stage of the illness (Nature 2010;468:187-93). Researchers are now investigating whether it is possible to detect these early signs and intervene before the onset of psychosis to minimize the impact of the disease, said Dr. Keshavan, who is also professor of psychiatry at the University of Pittsburgh.

The emergence of cognitive control and emotion regulation during adolescence are related to expansion of connectivity and fine-tuning of both excitatory and inhibitory neurotransmitter systems. At the same time, abstract thinking and executive function arise from increased efficiency at the expense of brain plasticity, or the ability of the brain to rewire itself in response to change. These processes might go haywire in those at risk for schizophrenia, and a combination of genetic and environmental factors could lead to a failure of inhibitory processes resulting in psychosis, he explained.

"Psychosis begins in adolescence, but schizophrenia really begins in childhood or even earlier. ... The risk-plasticity model of development of schizophrenia suggests several windows of opportunity for primary, secondary, and tertiary prevention," he said.

Several signs mark the early stages of disease. In one recent meta-analysis of 18 studies, individuals with schizophrenia demonstrated mean IQ scores of approximately half a standard deviation below those of healthy comparison subjects, years before the onset of psychotic symptoms (Am. J. Psychiatry 2008;165:579-87).

Certain biomarkers might help to identify those at risk. In a study from Dr. Keshavan’s work in Pittsburgh, at-risk relatives of schizophrenia patients who themselves had schizotypy performed less well on the Wisconsin Card Sort task, which assesses executive function, and showed age-related deficits on the oculomotor delayed-response task, compared with nonschizotypal relatives and healthy controls (Prog. Neuropsychopharmacol. Biol. Psychiatry 2006;30:230-8).

Two follow-up studies showed gray matter losses evolving during the premorbid phase among high-risk relatives, compared with control relatives, in areas mediating social cognition and overlapping with cognitive deficits (Neuroimage 2011;54S1:S272-9; Neuroimage 2011;54S1:S287-92).

Other data from Dr. Keshavan’s group at the University of Pittsburgh indirectly suggest that neurons do not appear to be lost in schizophrenia, but that a reduction in synaptic connectivity occurs leading to reduced brain plasticity (Schizophr. Res. 2010;119:47-51). Such a process might be reversible, he noted.

A variety of environmental factors have been implicated in triggering schizophrenia among individuals who already are genetically predisposed. These include obstetric complications (Ann. NY Acad. Sci. 2003;1008:269-75), exposure to the herpes simplex virus (Mol. Psychiatry 2007;12:105-13), and cannabis use (Schizophr. Res. 2008;99:1-6).

In a longitudinal study of 291 prodromal individuals who sought treatment, the risk of conversion to psychosis was 35% over a period of 2.5 years. Five baseline features independently predicted conversion risk: A genetic risk for schizophrenia with recent deterioration in functioning, higher levels of unusual thought content, higher levels of suspicion/paranoia, greater social impairment, and a history of substance abuse. Algorithms combining two or three of these variables resulted in positive predictive power of 68%-80%, significantly greater than with prodromal criteria alone (Arch. Gen. Psychiatry 2008;65:28-37).

For individuals identified as being at high risk for progression to psychosis, studies are suggesting that use of a variety of pharmacologic and nonpharmacologic preventive interventions during the prodrome might be of benefit.

In a small randomized trial, 31 outpatients with prodromal symptoms of schizophrenia received 5-15 mg/day olanzapine and 29 took placebo during a 1-year double-blind treatment period. No treatment was given in the subsequent year of follow-up. Although the difference in the rate of conversion during the treatment year was statistically insignificant, it was more than double in the placebo group – 38% vs. 16% with olanzapine (Am. J. Psychiatry 2006;163:790-9).

However, the olanzapine patients did gain significantly more weight (8.8 vs. 0.30 kg), Dr. Keshavan noted.

Cognitive therapy (CT) is another potential approach. A randomized controlled trial compared CT over 6 months with monthly monitoring in 58 patients who met criteria for an ultrahigh risk of developing a first episode of psychosis. Those receiving CT were less likely to be prescribed an antipsychotic medication over the subsequent 3 years. While CT did not affect transition to psychosis with two different measures, it did significantly reduce the likelihood of progression to psychosis after baseline cognitive factors were controlled for (Schizophr. Bull. 2007;33:682-7).

Omega-3 fatty acids also have been investigated, based on evidence that their levels might be deficient in schizophrenia patients, leading to alterations in neurotransmission among other processes.

In a randomized, double-blind placebo-controlled trial, 81 adolescents and young adults with subthreshold psychosis received 1.2 g/day of omega-3 polyunsaturated fatty acids (PUFAs) for 12 weeks, followed by a 40-week monitoring period. At 12 months, 2 of 41 in the omega-3 group (4.9%) and 11 of 40 (27.5%) in the placebo group had transitioned to psychotic disorder, a significant difference (Arch. Gen. Psychiatry 2010;67:146-54).

The omega-3s also significantly reduced positive symptoms, negative symptoms, general symptoms, and improved functioning, compared with placebo, with no difference in the incidence of adverse effects between the treatment groups. "This finding suggests that the omega-3s prevented the transition to psychosis. If this is the case, it would be significant for young people at high risk of developing schizophrenia or other psychotic disorders," Dr. Keshavan said.

Antiviral agents also might have prevention potential. In an unpublished study by Dr. Konasale M. Prasad in Dr. Keshavan’s Pittsburgh group, valacyclovir in patients with schizophrenia produced a trend toward improvement in working memory.

And finally, evidence suggests that an integrated neurocognitive and social-cognitive rehabilitation program using cognitive enhancement therapy (CET) can positively affect cognitive and functional outcomes. A total of 58 early-course outpatients with schizophrenia or schizoaffective disorder were randomly assigned to CET or enriched supportive therapy, an illness management intervention using psychoeducation and applied coping strategies. After 2 years, CET moderately enhanced neurocognitive function. Strong differential effects on social cognition, cognitive style, and social adjustment composites remained at year 2 and also extended to measures of symptomatology, particularly negative symptoms (Psychiatr. Serv. 2009;60:1468-76).

The University of Pittsburgh authors, of whom Dr. Keshavan was again the principal investigator, concluded "CET appears to be an effective approach to the remediation of cognitive deficits in early schizophrenia that may help reduce disability in this population. The remediation of such deficits should be an integral component of early intervention programs treating psychiatrically stable schizophrenia outpatients."

Another study, currently in press, showed that gray matter density increased with CET compared with enriched supportive therapy at 1 year, Dr. Keshavan said.

"The summary is that there are many promising hypotheses and more research is needed to develop proof of concept," he concluded.

Dr. Keshavan disclosed that he receives grant/research support from GlaxoSmithKline.

PITTSBURGH – Emerging evidence is leading to optimism that early interventions could prevent the onset of schizophrenia or reduce its impact on cognitive function.

Among psychiatric disorders, schizophrenia tends to manifest later in life than most, typically not until late adolescence or early adulthood. Yet, evidence suggests that brain changes actually occur much earlier in life among those destined to develop the disease, said Dr. Matcheri S. Keshavan, the Stanley Cobb Professor of Psychiatry at Harvard Medical School and vice chair of public psychiatry at Beth Israel Deaconess Medical Center and the Massachusetts Mental Health Center, all in Boston.

Indeed, schizophrenia is increasingly being viewed as a neurodevelopmental disorder with psychosis as a late and potentially preventable stage of the illness (Nature 2010;468:187-93). Researchers are now investigating whether it is possible to detect these early signs and intervene before the onset of psychosis to minimize the impact of the disease, said Dr. Keshavan, who is also professor of psychiatry at the University of Pittsburgh.

The emergence of cognitive control and emotion regulation during adolescence are related to expansion of connectivity and fine-tuning of both excitatory and inhibitory neurotransmitter systems. At the same time, abstract thinking and executive function arise from increased efficiency at the expense of brain plasticity, or the ability of the brain to rewire itself in response to change. These processes might go haywire in those at risk for schizophrenia, and a combination of genetic and environmental factors could lead to a failure of inhibitory processes resulting in psychosis, he explained.

"Psychosis begins in adolescence, but schizophrenia really begins in childhood or even earlier. ... The risk-plasticity model of development of schizophrenia suggests several windows of opportunity for primary, secondary, and tertiary prevention," he said.

Several signs mark the early stages of disease. In one recent meta-analysis of 18 studies, individuals with schizophrenia demonstrated mean IQ scores of approximately half a standard deviation below those of healthy comparison subjects, years before the onset of psychotic symptoms (Am. J. Psychiatry 2008;165:579-87).

Certain biomarkers might help to identify those at risk. In a study from Dr. Keshavan’s work in Pittsburgh, at-risk relatives of schizophrenia patients who themselves had schizotypy performed less well on the Wisconsin Card Sort task, which assesses executive function, and showed age-related deficits on the oculomotor delayed-response task, compared with nonschizotypal relatives and healthy controls (Prog. Neuropsychopharmacol. Biol. Psychiatry 2006;30:230-8).

Two follow-up studies showed gray matter losses evolving during the premorbid phase among high-risk relatives, compared with control relatives, in areas mediating social cognition and overlapping with cognitive deficits (Neuroimage 2011;54S1:S272-9; Neuroimage 2011;54S1:S287-92).

Other data from Dr. Keshavan’s group at the University of Pittsburgh indirectly suggest that neurons do not appear to be lost in schizophrenia, but that a reduction in synaptic connectivity occurs leading to reduced brain plasticity (Schizophr. Res. 2010;119:47-51). Such a process might be reversible, he noted.

A variety of environmental factors have been implicated in triggering schizophrenia among individuals who already are genetically predisposed. These include obstetric complications (Ann. NY Acad. Sci. 2003;1008:269-75), exposure to the herpes simplex virus (Mol. Psychiatry 2007;12:105-13), and cannabis use (Schizophr. Res. 2008;99:1-6).

In a longitudinal study of 291 prodromal individuals who sought treatment, the risk of conversion to psychosis was 35% over a period of 2.5 years. Five baseline features independently predicted conversion risk: A genetic risk for schizophrenia with recent deterioration in functioning, higher levels of unusual thought content, higher levels of suspicion/paranoia, greater social impairment, and a history of substance abuse. Algorithms combining two or three of these variables resulted in positive predictive power of 68%-80%, significantly greater than with prodromal criteria alone (Arch. Gen. Psychiatry 2008;65:28-37).

For individuals identified as being at high risk for progression to psychosis, studies are suggesting that use of a variety of pharmacologic and nonpharmacologic preventive interventions during the prodrome might be of benefit.

In a small randomized trial, 31 outpatients with prodromal symptoms of schizophrenia received 5-15 mg/day olanzapine and 29 took placebo during a 1-year double-blind treatment period. No treatment was given in the subsequent year of follow-up. Although the difference in the rate of conversion during the treatment year was statistically insignificant, it was more than double in the placebo group – 38% vs. 16% with olanzapine (Am. J. Psychiatry 2006;163:790-9).

However, the olanzapine patients did gain significantly more weight (8.8 vs. 0.30 kg), Dr. Keshavan noted.

Cognitive therapy (CT) is another potential approach. A randomized controlled trial compared CT over 6 months with monthly monitoring in 58 patients who met criteria for an ultrahigh risk of developing a first episode of psychosis. Those receiving CT were less likely to be prescribed an antipsychotic medication over the subsequent 3 years. While CT did not affect transition to psychosis with two different measures, it did significantly reduce the likelihood of progression to psychosis after baseline cognitive factors were controlled for (Schizophr. Bull. 2007;33:682-7).

Omega-3 fatty acids also have been investigated, based on evidence that their levels might be deficient in schizophrenia patients, leading to alterations in neurotransmission among other processes.

In a randomized, double-blind placebo-controlled trial, 81 adolescents and young adults with subthreshold psychosis received 1.2 g/day of omega-3 polyunsaturated fatty acids (PUFAs) for 12 weeks, followed by a 40-week monitoring period. At 12 months, 2 of 41 in the omega-3 group (4.9%) and 11 of 40 (27.5%) in the placebo group had transitioned to psychotic disorder, a significant difference (Arch. Gen. Psychiatry 2010;67:146-54).

The omega-3s also significantly reduced positive symptoms, negative symptoms, general symptoms, and improved functioning, compared with placebo, with no difference in the incidence of adverse effects between the treatment groups. "This finding suggests that the omega-3s prevented the transition to psychosis. If this is the case, it would be significant for young people at high risk of developing schizophrenia or other psychotic disorders," Dr. Keshavan said.

Antiviral agents also might have prevention potential. In an unpublished study by Dr. Konasale M. Prasad in Dr. Keshavan’s Pittsburgh group, valacyclovir in patients with schizophrenia produced a trend toward improvement in working memory.

And finally, evidence suggests that an integrated neurocognitive and social-cognitive rehabilitation program using cognitive enhancement therapy (CET) can positively affect cognitive and functional outcomes. A total of 58 early-course outpatients with schizophrenia or schizoaffective disorder were randomly assigned to CET or enriched supportive therapy, an illness management intervention using psychoeducation and applied coping strategies. After 2 years, CET moderately enhanced neurocognitive function. Strong differential effects on social cognition, cognitive style, and social adjustment composites remained at year 2 and also extended to measures of symptomatology, particularly negative symptoms (Psychiatr. Serv. 2009;60:1468-76).

The University of Pittsburgh authors, of whom Dr. Keshavan was again the principal investigator, concluded "CET appears to be an effective approach to the remediation of cognitive deficits in early schizophrenia that may help reduce disability in this population. The remediation of such deficits should be an integral component of early intervention programs treating psychiatrically stable schizophrenia outpatients."

Another study, currently in press, showed that gray matter density increased with CET compared with enriched supportive therapy at 1 year, Dr. Keshavan said.

"The summary is that there are many promising hypotheses and more research is needed to develop proof of concept," he concluded.

Dr. Keshavan disclosed that he receives grant/research support from GlaxoSmithKline.

PITTSBURGH – Emerging evidence is leading to optimism that early interventions could prevent the onset of schizophrenia or reduce its impact on cognitive function.

Among psychiatric disorders, schizophrenia tends to manifest later in life than most, typically not until late adolescence or early adulthood. Yet, evidence suggests that brain changes actually occur much earlier in life among those destined to develop the disease, said Dr. Matcheri S. Keshavan, the Stanley Cobb Professor of Psychiatry at Harvard Medical School and vice chair of public psychiatry at Beth Israel Deaconess Medical Center and the Massachusetts Mental Health Center, all in Boston.

Indeed, schizophrenia is increasingly being viewed as a neurodevelopmental disorder with psychosis as a late and potentially preventable stage of the illness (Nature 2010;468:187-93). Researchers are now investigating whether it is possible to detect these early signs and intervene before the onset of psychosis to minimize the impact of the disease, said Dr. Keshavan, who is also professor of psychiatry at the University of Pittsburgh.

The emergence of cognitive control and emotion regulation during adolescence are related to expansion of connectivity and fine-tuning of both excitatory and inhibitory neurotransmitter systems. At the same time, abstract thinking and executive function arise from increased efficiency at the expense of brain plasticity, or the ability of the brain to rewire itself in response to change. These processes might go haywire in those at risk for schizophrenia, and a combination of genetic and environmental factors could lead to a failure of inhibitory processes resulting in psychosis, he explained.

"Psychosis begins in adolescence, but schizophrenia really begins in childhood or even earlier. ... The risk-plasticity model of development of schizophrenia suggests several windows of opportunity for primary, secondary, and tertiary prevention," he said.

Several signs mark the early stages of disease. In one recent meta-analysis of 18 studies, individuals with schizophrenia demonstrated mean IQ scores of approximately half a standard deviation below those of healthy comparison subjects, years before the onset of psychotic symptoms (Am. J. Psychiatry 2008;165:579-87).

Certain biomarkers might help to identify those at risk. In a study from Dr. Keshavan’s work in Pittsburgh, at-risk relatives of schizophrenia patients who themselves had schizotypy performed less well on the Wisconsin Card Sort task, which assesses executive function, and showed age-related deficits on the oculomotor delayed-response task, compared with nonschizotypal relatives and healthy controls (Prog. Neuropsychopharmacol. Biol. Psychiatry 2006;30:230-8).

Two follow-up studies showed gray matter losses evolving during the premorbid phase among high-risk relatives, compared with control relatives, in areas mediating social cognition and overlapping with cognitive deficits (Neuroimage 2011;54S1:S272-9; Neuroimage 2011;54S1:S287-92).

Other data from Dr. Keshavan’s group at the University of Pittsburgh indirectly suggest that neurons do not appear to be lost in schizophrenia, but that a reduction in synaptic connectivity occurs leading to reduced brain plasticity (Schizophr. Res. 2010;119:47-51). Such a process might be reversible, he noted.

A variety of environmental factors have been implicated in triggering schizophrenia among individuals who already are genetically predisposed. These include obstetric complications (Ann. NY Acad. Sci. 2003;1008:269-75), exposure to the herpes simplex virus (Mol. Psychiatry 2007;12:105-13), and cannabis use (Schizophr. Res. 2008;99:1-6).

In a longitudinal study of 291 prodromal individuals who sought treatment, the risk of conversion to psychosis was 35% over a period of 2.5 years. Five baseline features independently predicted conversion risk: A genetic risk for schizophrenia with recent deterioration in functioning, higher levels of unusual thought content, higher levels of suspicion/paranoia, greater social impairment, and a history of substance abuse. Algorithms combining two or three of these variables resulted in positive predictive power of 68%-80%, significantly greater than with prodromal criteria alone (Arch. Gen. Psychiatry 2008;65:28-37).

For individuals identified as being at high risk for progression to psychosis, studies are suggesting that use of a variety of pharmacologic and nonpharmacologic preventive interventions during the prodrome might be of benefit.

In a small randomized trial, 31 outpatients with prodromal symptoms of schizophrenia received 5-15 mg/day olanzapine and 29 took placebo during a 1-year double-blind treatment period. No treatment was given in the subsequent year of follow-up. Although the difference in the rate of conversion during the treatment year was statistically insignificant, it was more than double in the placebo group – 38% vs. 16% with olanzapine (Am. J. Psychiatry 2006;163:790-9).

However, the olanzapine patients did gain significantly more weight (8.8 vs. 0.30 kg), Dr. Keshavan noted.

Cognitive therapy (CT) is another potential approach. A randomized controlled trial compared CT over 6 months with monthly monitoring in 58 patients who met criteria for an ultrahigh risk of developing a first episode of psychosis. Those receiving CT were less likely to be prescribed an antipsychotic medication over the subsequent 3 years. While CT did not affect transition to psychosis with two different measures, it did significantly reduce the likelihood of progression to psychosis after baseline cognitive factors were controlled for (Schizophr. Bull. 2007;33:682-7).

Omega-3 fatty acids also have been investigated, based on evidence that their levels might be deficient in schizophrenia patients, leading to alterations in neurotransmission among other processes.

In a randomized, double-blind placebo-controlled trial, 81 adolescents and young adults with subthreshold psychosis received 1.2 g/day of omega-3 polyunsaturated fatty acids (PUFAs) for 12 weeks, followed by a 40-week monitoring period. At 12 months, 2 of 41 in the omega-3 group (4.9%) and 11 of 40 (27.5%) in the placebo group had transitioned to psychotic disorder, a significant difference (Arch. Gen. Psychiatry 2010;67:146-54).

The omega-3s also significantly reduced positive symptoms, negative symptoms, general symptoms, and improved functioning, compared with placebo, with no difference in the incidence of adverse effects between the treatment groups. "This finding suggests that the omega-3s prevented the transition to psychosis. If this is the case, it would be significant for young people at high risk of developing schizophrenia or other psychotic disorders," Dr. Keshavan said.

Antiviral agents also might have prevention potential. In an unpublished study by Dr. Konasale M. Prasad in Dr. Keshavan’s Pittsburgh group, valacyclovir in patients with schizophrenia produced a trend toward improvement in working memory.

And finally, evidence suggests that an integrated neurocognitive and social-cognitive rehabilitation program using cognitive enhancement therapy (CET) can positively affect cognitive and functional outcomes. A total of 58 early-course outpatients with schizophrenia or schizoaffective disorder were randomly assigned to CET or enriched supportive therapy, an illness management intervention using psychoeducation and applied coping strategies. After 2 years, CET moderately enhanced neurocognitive function. Strong differential effects on social cognition, cognitive style, and social adjustment composites remained at year 2 and also extended to measures of symptomatology, particularly negative symptoms (Psychiatr. Serv. 2009;60:1468-76).

The University of Pittsburgh authors, of whom Dr. Keshavan was again the principal investigator, concluded "CET appears to be an effective approach to the remediation of cognitive deficits in early schizophrenia that may help reduce disability in this population. The remediation of such deficits should be an integral component of early intervention programs treating psychiatrically stable schizophrenia outpatients."

Another study, currently in press, showed that gray matter density increased with CET compared with enriched supportive therapy at 1 year, Dr. Keshavan said.

"The summary is that there are many promising hypotheses and more research is needed to develop proof of concept," he concluded.

Dr. Keshavan disclosed that he receives grant/research support from GlaxoSmithKline.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.

The number of people in the United States with diabetes has now risen to nearly 26 million, while another 79 million have prediabetes, according to data released Jan. 26 by the Centers for Disease Control and Prevention.

Diabetes is present in 8.3% of all Americans and 11.3% of those aged 20 years and older, according to the CDC’s 2011 National Diabetes Fact Sheet. More than a third (35%) of those aged 20 and older have prediabetes. Over a quarter of Americans aged 65 years and older have diabetes, and half have prediabetes.

Among those with diabetes, about 27% (or 7 million people) are undiagnosed.

"Although consecutive fact sheets aren’t meant to determine trends, it’s discouraging that the proportion of people undiagnosed has remained at about one in four since the last fact sheet [was published in 2008]. This is after falling from one in two and then one in three over the decade prior to 2007," said Dr. Sue Kirkman, senior vice president of medical affairs and community information for the American Diabetes Association, in an interview.

"The take-home message is what ADA has been recommending all along: Health care professionals need to assess patients for risk factors and test those who are at risk, including those who are overweight; have a family history of diabetes or gestational diabetes, high-risk ethnicity, hypertension, [or] dyslipidemia; or are [older than age 45]," Dr. Kirkman said.

In 2008, the CDC estimated that 23.6 million Americans (or 7.8% of the population) had diabetes, and another 57 million adults had prediabetes. The rise in diabetes prevalence seen in the 2011 data results from both the fact that more people are developing the disease and the fact that people are living longer with it, thanks to better management of cardiovascular risk factors and a reduction in complications such as renal failure and amputations. These new estimates of national prevalence are the first to include cases diagnosed using hemoglobin A1c, which means that the estimates of prediabetes and diabetes may not be directly comparable to previous estimates, the agency noted.

Dr. Kirkman said she believes that the impact of this change is greater for prediabetes than for diabetes. "The incorporation of A1C into the diagnosis of diabetes didn’t make a significant difference in the prevalence of diabetes, so the 25.8 million estimate reflects a true increase in prevalence. In contrast, adding the A1C does increase the number estimated to have prediabetes a lot, although there is also an underlying true increase in prevalence there as well," she noted.

She advised that people with prediabetes be referred to programs that can support them in losing weight and exercising. "With the roll-out of the National Diabetes Prevention programs in the community, such as through YMCAs, the hope is that in the next few years there will be more and more programs to refer people to."

Dr. Kirkman stated that she has no financial disclosures.