Sharon Worcester

Intravenous immune globulin has been suggested as a possible therapy for preventing congenital heart block caused by neonatal lupus, and early data from a study of the treatment indicate that further study is warranted.

Of five women with a previous fetus affected by neonatal lupus—who thus are at increased risk of having a baby with congenital heart block—who were enrolled at press time in the Preventive IVIG Therapy for Congenital Heart Block (PITCH) study, three had given birth to babies without congenital heart block following IVIG treatment, one was still undergoing treatment but showed no fetal echocardiographic evidence of congenital heart block, and one had not reached 12 weeks' gestation and therefore had not begun treatment, principal investigator Dr. Jill Buyon said during an informational teleconference on the study. At least 19 total patients are needed to adequately power this open-label first- phase of the PITCH study, which is sponsored by New York University and the Alliance for Lupus Research, said Dr. Buyon, professor of medicine and vice chair of the department of rheumatology at New York University.

An additional 35 patients will be needed for the second phase of the study, which will proceed if fewer than 3 of the 19 women in the first phase have children with second- or third-degree heart block.

Neonatal lupus can affect babies of mothers with SSA/Ro and SSB/La autoantibodies, and can appear as a transient rash that disappears by the time the baby is about 6 months old, or, in rare cases, as a transient abnormal blood or liver condition. In some cases, however, congenital heart block occurs in affected fetuses, causing permanent heart damage and fetal death.

The risk of congenital heart block is about 2% in a first pregnancy for women with anti-Ro and anti-La antibodies, but the risk jumps to 20% in subsequent pregnancies in women who have had a previous child with congenital heart block or neonatal lupus-related rash, coinvestigator Dr. Deborah Friedman of St. Barnabas Medical Center in Livingston, N.J., said.

Since no therapy has been successful for the treatment of complete heart block, the focus has shifted to prevention of the condition, which appears to occur because of scarring of the conduction system that results from inflammation triggered by the mother's antibodies.

The scarred heart beats extremely slowly, and 20% of affected babies die—most of them within 2 weeks and in utero. Surviving babies almost always require permanent implantation of a pacemaker.

Giving IVIG to at-risk mothers was suggested as a potential preventative therapy because it has the potential to lower maternal antibody levels, thereby reducing fetal exposure, and also to influence effector mechanisms in the fetus itself. Furthermore, IVIG has been shown to be safe in pregnancy, Dr. Buyon noted.

Having a total of 19 women enrolled in the first phase of PITCH will provide adequate power to demonstrate a reduction of risk from 20% to 5% in women with a previously affected child. Patients will receive 400 mg/kg IVIG every 3 weeks for a total of five treatments from weeks 12–24 of pregnancy.

IVIG will be considered efficacious and worthy of further study if fewer than six women in phase II of PITCH have a child with advanced heart block.

Participants should be aged 18–50 years, have a current intrauterine pregnancy of less than 12 weeks, and have circulating SSA/Ro and/or SSB/La antibodies. Participants also should have a previous child with congenital heart block of any degree, which has been documented by EKG and/or echocardiogram; with confirmed characteristic lupus rash; or with congenital heart block and rash.

Women with rheumatic disease can participate if they aren't taking more than 20 mg/day of prednisone. Other exclusion criteria include conditions that would contraindicate the use of IVIG such as a prior serious IVIG infusion reaction, known IgA deficiency, intolerance of volume load, and nephrotic syndrome. Those with a fetus with structural lesions that could cause congenital heart block also are excluded.

Those interested in enrolling patients in PITCH should refer to ClinicalTrials.gov identifier NCT00460928, and should contact research administrator, Lena Geffrard, by calling 212-263-2255 or sending an e-mail to [email protected]

Intravenous immune globulin has been suggested as a possible therapy for preventing congenital heart block caused by neonatal lupus, and early data from a study of the treatment indicate that further study is warranted.

Of five women with a previous fetus affected by neonatal lupus—who thus are at increased risk of having a baby with congenital heart block—who were enrolled at press time in the Preventive IVIG Therapy for Congenital Heart Block (PITCH) study, three had given birth to babies without congenital heart block following IVIG treatment, one was still undergoing treatment but showed no fetal echocardiographic evidence of congenital heart block, and one had not reached 12 weeks' gestation and therefore had not begun treatment, principal investigator Dr. Jill Buyon said during an informational teleconference on the study. At least 19 total patients are needed to adequately power this open-label first- phase of the PITCH study, which is sponsored by New York University and the Alliance for Lupus Research, said Dr. Buyon, professor of medicine and vice chair of the department of rheumatology at New York University.

An additional 35 patients will be needed for the second phase of the study, which will proceed if fewer than 3 of the 19 women in the first phase have children with second- or third-degree heart block.

Neonatal lupus can affect babies of mothers with SSA/Ro and SSB/La autoantibodies, and can appear as a transient rash that disappears by the time the baby is about 6 months old, or, in rare cases, as a transient abnormal blood or liver condition. In some cases, however, congenital heart block occurs in affected fetuses, causing permanent heart damage and fetal death.

The risk of congenital heart block is about 2% in a first pregnancy for women with anti-Ro and anti-La antibodies, but the risk jumps to 20% in subsequent pregnancies in women who have had a previous child with congenital heart block or neonatal lupus-related rash, coinvestigator Dr. Deborah Friedman of St. Barnabas Medical Center in Livingston, N.J., said.

Since no therapy has been successful for the treatment of complete heart block, the focus has shifted to prevention of the condition, which appears to occur because of scarring of the conduction system that results from inflammation triggered by the mother's antibodies.

The scarred heart beats extremely slowly, and 20% of affected babies die—most of them within 2 weeks and in utero. Surviving babies almost always require permanent implantation of a pacemaker.

Giving IVIG to at-risk mothers was suggested as a potential preventative therapy because it has the potential to lower maternal antibody levels, thereby reducing fetal exposure, and also to influence effector mechanisms in the fetus itself. Furthermore, IVIG has been shown to be safe in pregnancy, Dr. Buyon noted.

Having a total of 19 women enrolled in the first phase of PITCH will provide adequate power to demonstrate a reduction of risk from 20% to 5% in women with a previously affected child. Patients will receive 400 mg/kg IVIG every 3 weeks for a total of five treatments from weeks 12–24 of pregnancy.

IVIG will be considered efficacious and worthy of further study if fewer than six women in phase II of PITCH have a child with advanced heart block.

Participants should be aged 18–50 years, have a current intrauterine pregnancy of less than 12 weeks, and have circulating SSA/Ro and/or SSB/La antibodies. Participants also should have a previous child with congenital heart block of any degree, which has been documented by EKG and/or echocardiogram; with confirmed characteristic lupus rash; or with congenital heart block and rash.

Women with rheumatic disease can participate if they aren't taking more than 20 mg/day of prednisone. Other exclusion criteria include conditions that would contraindicate the use of IVIG such as a prior serious IVIG infusion reaction, known IgA deficiency, intolerance of volume load, and nephrotic syndrome. Those with a fetus with structural lesions that could cause congenital heart block also are excluded.

Those interested in enrolling patients in PITCH should refer to ClinicalTrials.gov identifier NCT00460928, and should contact research administrator, Lena Geffrard, by calling 212-263-2255 or sending an e-mail to [email protected]

Intravenous immune globulin has been suggested as a possible therapy for preventing congenital heart block caused by neonatal lupus, and early data from a study of the treatment indicate that further study is warranted.

Of five women with a previous fetus affected by neonatal lupus—who thus are at increased risk of having a baby with congenital heart block—who were enrolled at press time in the Preventive IVIG Therapy for Congenital Heart Block (PITCH) study, three had given birth to babies without congenital heart block following IVIG treatment, one was still undergoing treatment but showed no fetal echocardiographic evidence of congenital heart block, and one had not reached 12 weeks' gestation and therefore had not begun treatment, principal investigator Dr. Jill Buyon said during an informational teleconference on the study. At least 19 total patients are needed to adequately power this open-label first- phase of the PITCH study, which is sponsored by New York University and the Alliance for Lupus Research, said Dr. Buyon, professor of medicine and vice chair of the department of rheumatology at New York University.

An additional 35 patients will be needed for the second phase of the study, which will proceed if fewer than 3 of the 19 women in the first phase have children with second- or third-degree heart block.

Neonatal lupus can affect babies of mothers with SSA/Ro and SSB/La autoantibodies, and can appear as a transient rash that disappears by the time the baby is about 6 months old, or, in rare cases, as a transient abnormal blood or liver condition. In some cases, however, congenital heart block occurs in affected fetuses, causing permanent heart damage and fetal death.

The risk of congenital heart block is about 2% in a first pregnancy for women with anti-Ro and anti-La antibodies, but the risk jumps to 20% in subsequent pregnancies in women who have had a previous child with congenital heart block or neonatal lupus-related rash, coinvestigator Dr. Deborah Friedman of St. Barnabas Medical Center in Livingston, N.J., said.

Since no therapy has been successful for the treatment of complete heart block, the focus has shifted to prevention of the condition, which appears to occur because of scarring of the conduction system that results from inflammation triggered by the mother's antibodies.

The scarred heart beats extremely slowly, and 20% of affected babies die—most of them within 2 weeks and in utero. Surviving babies almost always require permanent implantation of a pacemaker.

Giving IVIG to at-risk mothers was suggested as a potential preventative therapy because it has the potential to lower maternal antibody levels, thereby reducing fetal exposure, and also to influence effector mechanisms in the fetus itself. Furthermore, IVIG has been shown to be safe in pregnancy, Dr. Buyon noted.

Having a total of 19 women enrolled in the first phase of PITCH will provide adequate power to demonstrate a reduction of risk from 20% to 5% in women with a previously affected child. Patients will receive 400 mg/kg IVIG every 3 weeks for a total of five treatments from weeks 12–24 of pregnancy.

IVIG will be considered efficacious and worthy of further study if fewer than six women in phase II of PITCH have a child with advanced heart block.

Participants should be aged 18–50 years, have a current intrauterine pregnancy of less than 12 weeks, and have circulating SSA/Ro and/or SSB/La antibodies. Participants also should have a previous child with congenital heart block of any degree, which has been documented by EKG and/or echocardiogram; with confirmed characteristic lupus rash; or with congenital heart block and rash.

Women with rheumatic disease can participate if they aren't taking more than 20 mg/day of prednisone. Other exclusion criteria include conditions that would contraindicate the use of IVIG such as a prior serious IVIG infusion reaction, known IgA deficiency, intolerance of volume load, and nephrotic syndrome. Those with a fetus with structural lesions that could cause congenital heart block also are excluded.

Those interested in enrolling patients in PITCH should refer to ClinicalTrials.gov identifier NCT00460928, and should contact research administrator, Lena Geffrard, by calling 212-263-2255 or sending an e-mail to [email protected]

NEW ORLEANS — The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, said Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that without effective HIV treatment, long-standing adverse effects can occur as a result of subcortical and cortical insult.

The effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain—all of which are common in HIV patients and may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a personal or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems such as sleep and pain disorders, fatigue, and sexual dysfunction also occur frequently and, like mood and other psychiatric disorders, should be addressed in these patients.

Depression Risk Factors in HIV

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ An inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure and, in some cases, treatment success (for example, when a patient expects to die but is treated successfully and is subsequently haunted by fears that the treatment will fail and that he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS — The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, said Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that without effective HIV treatment, long-standing adverse effects can occur as a result of subcortical and cortical insult.

The effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain—all of which are common in HIV patients and may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a personal or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems such as sleep and pain disorders, fatigue, and sexual dysfunction also occur frequently and, like mood and other psychiatric disorders, should be addressed in these patients.

Depression Risk Factors in HIV

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ An inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure and, in some cases, treatment success (for example, when a patient expects to die but is treated successfully and is subsequently haunted by fears that the treatment will fail and that he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS — The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, said Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that without effective HIV treatment, long-standing adverse effects can occur as a result of subcortical and cortical insult.

The effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain—all of which are common in HIV patients and may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a personal or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems such as sleep and pain disorders, fatigue, and sexual dysfunction also occur frequently and, like mood and other psychiatric disorders, should be addressed in these patients.

Depression Risk Factors in HIV

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ An inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure and, in some cases, treatment success (for example, when a patient expects to die but is treated successfully and is subsequently haunted by fears that the treatment will fail and that he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

Incorporating a parent-completed developmental screening tool into 12- and 24-month well-child office visits in a busy practice increased referrals for further evaluation by 224% in a recent study.

The finding underscores the need for increased attention to providing developmental screening in the office setting, as is recommended by the American Academy of Pediatrics, according to Dr. Kevin Marks, one of the study authors.

Indeed, a July 2006 AAP policy statement calls for formal, systematic, developmental screening at 9 months, 18 months, and between 24 and 30 months of age, and for developmental surveillance at every pediatric visit (Pediatrics 2006;118: 405–20), Dr. Nancy Murphy, chair of the AAP Council on Child Development, and associate professor of pediatrics at the University of Utah, Salt Lake City, said in an interview.

The formal screening is particularly important, because it seems that the very children who benefit the most from early intervention—such as children with mild delays, children from low socioeconomic backgrounds, and younger children with early signs of autism—often are the same children whom physicians fail to identify in a timely manner without the help of universal, periodic, standardized developmental screening, said Dr. Marks of PeaceHealth Medical Group in Eugene, Oregon, where the study was conducted.

For their study, Dr. Marks and his colleagues asked 1,428 caregivers who brought a child in for a 12- or 24-month visit to complete the validated Ages and Stages Questionnaire (ASQ) in the office or to take it home and mail it back; 54% did so. Twenty health care workers—18 board-certified pediatricians and 2 nurse practitioners—who were blinded to the ASQ results, also evaluated the patients using the Pediatric Developmental Impression (PDI), a tool developed especially for the study to capture physician clinical impression of development.

Children with previously diagnosed developmental delays or disorders were excluded from the study.

A total of 107 referrals (82 unique cases) were sent to a local Part C Individuals with Disabilities Education Act (IDEA) early childhood development agency for further evaluation based on the combined ASQ and PDI results, compared with only 33 referrals made in a control year (224% increase). Based on the PDI alone, 68% of the 107 referred during the study period would not have been referred based on clinical impression alone.

Thirty-eight of the patients referred qualified for special services, an additional 44 were scheduled for developmental monitoring because of “suspect development that may lead to future eligibility,” and 25 did not qualify for services or monitoring under strict state IDEA eligibility requirements, Hollie Hix-Small, Ph.D., of the University of Oregon, Eugene, and her colleagues (including Dr. Marks) reported (Pediatrics 2007;120:381–9). Two of the study authors, Jane Squires, Ph.D., and Dr. Robert Nickel, are ASQ authors who receive publication royalties.

Of note, 96% of the referrals made based on the PDI were children who qualified for developmental services as determined following referral, suggesting that physicians should “trust their intuitions about a child's developmental status if they suspect a delay,” Dr. Marks said in an interview.

Referral based on the PDI was significantly predicted by suspected communication delay (odds ratio 136.50) and gross motor delay (odds ratio 58.80).

However, physicians must realize their observational limitations since 37 of 82 early intervention-eligible or monitored children would have been missed on physician impression alone, he added.

The findings of the study prompted a permanent—and more extensive—change in the practice's developmental screening protocol, Dr. Marks said.

“We quickly changed to a 12-, 24-, and 36-month universal ASQ screening schedule and will soon likely add on the 18-month ASQ,” Dr. Marks said, noting that the greatest effects of the use of the ASQ in the office-setting in the study were seen in the 12-month-old children. For example, 5 referrals were made in the 12-month age group in the control year, compared with 33 based on the ASQ in the screening year and a total of 40 based on the combined ASQ and PDI referrals in the screening year; in the 24-month-old age group, 28 referrals were made in the control year, compared with 44 based on the ASQ in the screening year and a total of 67 based on the combined ASQ and PDI referrals in the screening year.

“We have also been heavily encouraging Medicaid, younger [under 21 years old] and Spanish-speaking parents to fill out the ASQ before or immediately after the well-child visit,” he said, explaining that this tactic has improved the poststudy ASQ return rates.

While the 54% return rate is adequate for study purposes, it is important that a better rate be achieved in routine practice, he noted.

The approach used in the study—completing the ASQ in the office or mailing it back later—proved feasible.

Physicians should 'trust their intuitions about a child's developmental status if they suspect a delay.' DR. MARKS

Incorporating a parent-completed developmental screening tool into 12- and 24-month well-child office visits in a busy practice increased referrals for further evaluation by 224% in a recent study.

The finding underscores the need for increased attention to providing developmental screening in the office setting, as is recommended by the American Academy of Pediatrics, according to Dr. Kevin Marks, one of the study authors.

Indeed, a July 2006 AAP policy statement calls for formal, systematic, developmental screening at 9 months, 18 months, and between 24 and 30 months of age, and for developmental surveillance at every pediatric visit (Pediatrics 2006;118: 405–20), Dr. Nancy Murphy, chair of the AAP Council on Child Development, and associate professor of pediatrics at the University of Utah, Salt Lake City, said in an interview.

The formal screening is particularly important, because it seems that the very children who benefit the most from early intervention—such as children with mild delays, children from low socioeconomic backgrounds, and younger children with early signs of autism—often are the same children whom physicians fail to identify in a timely manner without the help of universal, periodic, standardized developmental screening, said Dr. Marks of PeaceHealth Medical Group in Eugene, Oregon, where the study was conducted.

For their study, Dr. Marks and his colleagues asked 1,428 caregivers who brought a child in for a 12- or 24-month visit to complete the validated Ages and Stages Questionnaire (ASQ) in the office or to take it home and mail it back; 54% did so. Twenty health care workers—18 board-certified pediatricians and 2 nurse practitioners—who were blinded to the ASQ results, also evaluated the patients using the Pediatric Developmental Impression (PDI), a tool developed especially for the study to capture physician clinical impression of development.

Children with previously diagnosed developmental delays or disorders were excluded from the study.

A total of 107 referrals (82 unique cases) were sent to a local Part C Individuals with Disabilities Education Act (IDEA) early childhood development agency for further evaluation based on the combined ASQ and PDI results, compared with only 33 referrals made in a control year (224% increase). Based on the PDI alone, 68% of the 107 referred during the study period would not have been referred based on clinical impression alone.

Thirty-eight of the patients referred qualified for special services, an additional 44 were scheduled for developmental monitoring because of “suspect development that may lead to future eligibility,” and 25 did not qualify for services or monitoring under strict state IDEA eligibility requirements, Hollie Hix-Small, Ph.D., of the University of Oregon, Eugene, and her colleagues (including Dr. Marks) reported (Pediatrics 2007;120:381–9). Two of the study authors, Jane Squires, Ph.D., and Dr. Robert Nickel, are ASQ authors who receive publication royalties.

Of note, 96% of the referrals made based on the PDI were children who qualified for developmental services as determined following referral, suggesting that physicians should “trust their intuitions about a child's developmental status if they suspect a delay,” Dr. Marks said in an interview.

Referral based on the PDI was significantly predicted by suspected communication delay (odds ratio 136.50) and gross motor delay (odds ratio 58.80).

However, physicians must realize their observational limitations since 37 of 82 early intervention-eligible or monitored children would have been missed on physician impression alone, he added.

The findings of the study prompted a permanent—and more extensive—change in the practice's developmental screening protocol, Dr. Marks said.

“We quickly changed to a 12-, 24-, and 36-month universal ASQ screening schedule and will soon likely add on the 18-month ASQ,” Dr. Marks said, noting that the greatest effects of the use of the ASQ in the office-setting in the study were seen in the 12-month-old children. For example, 5 referrals were made in the 12-month age group in the control year, compared with 33 based on the ASQ in the screening year and a total of 40 based on the combined ASQ and PDI referrals in the screening year; in the 24-month-old age group, 28 referrals were made in the control year, compared with 44 based on the ASQ in the screening year and a total of 67 based on the combined ASQ and PDI referrals in the screening year.

“We have also been heavily encouraging Medicaid, younger [under 21 years old] and Spanish-speaking parents to fill out the ASQ before or immediately after the well-child visit,” he said, explaining that this tactic has improved the poststudy ASQ return rates.

While the 54% return rate is adequate for study purposes, it is important that a better rate be achieved in routine practice, he noted.

The approach used in the study—completing the ASQ in the office or mailing it back later—proved feasible.

Physicians should 'trust their intuitions about a child's developmental status if they suspect a delay.' DR. MARKS

Incorporating a parent-completed developmental screening tool into 12- and 24-month well-child office visits in a busy practice increased referrals for further evaluation by 224% in a recent study.

The finding underscores the need for increased attention to providing developmental screening in the office setting, as is recommended by the American Academy of Pediatrics, according to Dr. Kevin Marks, one of the study authors.

Indeed, a July 2006 AAP policy statement calls for formal, systematic, developmental screening at 9 months, 18 months, and between 24 and 30 months of age, and for developmental surveillance at every pediatric visit (Pediatrics 2006;118: 405–20), Dr. Nancy Murphy, chair of the AAP Council on Child Development, and associate professor of pediatrics at the University of Utah, Salt Lake City, said in an interview.

The formal screening is particularly important, because it seems that the very children who benefit the most from early intervention—such as children with mild delays, children from low socioeconomic backgrounds, and younger children with early signs of autism—often are the same children whom physicians fail to identify in a timely manner without the help of universal, periodic, standardized developmental screening, said Dr. Marks of PeaceHealth Medical Group in Eugene, Oregon, where the study was conducted.

For their study, Dr. Marks and his colleagues asked 1,428 caregivers who brought a child in for a 12- or 24-month visit to complete the validated Ages and Stages Questionnaire (ASQ) in the office or to take it home and mail it back; 54% did so. Twenty health care workers—18 board-certified pediatricians and 2 nurse practitioners—who were blinded to the ASQ results, also evaluated the patients using the Pediatric Developmental Impression (PDI), a tool developed especially for the study to capture physician clinical impression of development.

Children with previously diagnosed developmental delays or disorders were excluded from the study.

A total of 107 referrals (82 unique cases) were sent to a local Part C Individuals with Disabilities Education Act (IDEA) early childhood development agency for further evaluation based on the combined ASQ and PDI results, compared with only 33 referrals made in a control year (224% increase). Based on the PDI alone, 68% of the 107 referred during the study period would not have been referred based on clinical impression alone.

Thirty-eight of the patients referred qualified for special services, an additional 44 were scheduled for developmental monitoring because of “suspect development that may lead to future eligibility,” and 25 did not qualify for services or monitoring under strict state IDEA eligibility requirements, Hollie Hix-Small, Ph.D., of the University of Oregon, Eugene, and her colleagues (including Dr. Marks) reported (Pediatrics 2007;120:381–9). Two of the study authors, Jane Squires, Ph.D., and Dr. Robert Nickel, are ASQ authors who receive publication royalties.

Of note, 96% of the referrals made based on the PDI were children who qualified for developmental services as determined following referral, suggesting that physicians should “trust their intuitions about a child's developmental status if they suspect a delay,” Dr. Marks said in an interview.

Referral based on the PDI was significantly predicted by suspected communication delay (odds ratio 136.50) and gross motor delay (odds ratio 58.80).

However, physicians must realize their observational limitations since 37 of 82 early intervention-eligible or monitored children would have been missed on physician impression alone, he added.

The findings of the study prompted a permanent—and more extensive—change in the practice's developmental screening protocol, Dr. Marks said.

“We quickly changed to a 12-, 24-, and 36-month universal ASQ screening schedule and will soon likely add on the 18-month ASQ,” Dr. Marks said, noting that the greatest effects of the use of the ASQ in the office-setting in the study were seen in the 12-month-old children. For example, 5 referrals were made in the 12-month age group in the control year, compared with 33 based on the ASQ in the screening year and a total of 40 based on the combined ASQ and PDI referrals in the screening year; in the 24-month-old age group, 28 referrals were made in the control year, compared with 44 based on the ASQ in the screening year and a total of 67 based on the combined ASQ and PDI referrals in the screening year.

“We have also been heavily encouraging Medicaid, younger [under 21 years old] and Spanish-speaking parents to fill out the ASQ before or immediately after the well-child visit,” he said, explaining that this tactic has improved the poststudy ASQ return rates.

While the 54% return rate is adequate for study purposes, it is important that a better rate be achieved in routine practice, he noted.

The approach used in the study—completing the ASQ in the office or mailing it back later—proved feasible.

Physicians should 'trust their intuitions about a child's developmental status if they suspect a delay.' DR. MARKS

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

NEW ORLEANS – For neurologic and psychiatric issues in HIV patients, several factors should be considered, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

Psychopharmacology should be used carefully, and patients should be monitored for CNS effects.

In addition, drug-drug interactions should be considered. It is important to keep in mind, for example, that HIV medications may alter absorption of other medications and that induction/inhibition of CP450 may alter drug levels, Dr. Forstein noted.

Common treatments for depression in HIV include selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, novel antidepressants, tricyclic antidepressants, psychostimulants, and hormonal treatments.

The start-low/go-slow approach often taken with elderly patients should be applied here as well.

Comorbid substance abuse should be monitored; several dangerous interactions can occur between HIV treatments and recreational drugs, said Dr. Forstein, who is with the department of psychiatry at the Harvard School of Medicine, Boston.

As for psychotherapy, several common themes among HIV patients have emerged and should be addressed, including:

▸ Loss.

▸ Anger.

▸ Control (decision making).

▸ Death and dying.

▸ Impact of HIV on partners and children.

▸ Fear.

▸ Disclosure.

▸ Sexuality.

▸ Spirituality.

▸ Guilt and regret.

▸ Self-criticism and self-esteem issues.

▸ Stigma and discrimination.

▸ Suicide, including physician-assisted suicide.

Importantly, several effective strategies are available for the management of mood disorders and psychiatric complications in HIV patients, Dr. Forstein said.

One study showed that about half of depressed HIV patients were not treated with antidepressants, and those not treated had 50% lower survival than those who were treated.

All HIV patients who have mood disorders or other psychiatric symptoms should be offered aggressive and timely treatment, he concluded.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

NEW ORLEANS – The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain–all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.

For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.

“It may be a question of how much inflammation is in the brain itself,” he said.

As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a history of or family history of a mood disorder, and alcohol or drug use.

It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.

Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.

Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems, such as sleep and pain disorders; fatigue; and sexual dysfunction also occur frequently, and like mood and other psychiatric disorders, should be addressed in these patients.

Probable Risk Factors for Depression

▸ Personal history of a mood disorder.

▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.

▸ Current alcohol or drug use.

▸ Inadequate social support system.

▸ Nondisclosure of HIV-positive status.

▸ Multiple losses.

▸ Disease progression.

▸ Treatment failure, and in some cases–treatment success (for example, when a patient expects to die but is treated successfully and then fears constantly that the treatment will subsequently fail and he or she will be faced with preparing again for death).

In addition, women are twice as likely as men to develop depression, regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson professor and associate chair in the department of psychiatry and behavioral sciences at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

“My immediate response is that the government is putting the cart before the horse insofar as years of inadequate or no funding for drug treatment have left limited resources for physicians to refer to if patients screen positive,” said Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn. “Furthermore, I have concerns about the utility of 'brief interventions' for substance use and whether physicians who bill for these are adequately trained to deliver them.”

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis. “Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15–30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. According to the White House statement, they will enable efficient screening services for subtance abuse (see sidebar), and increase the likelihood of interventions. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The codes provide medical professionals a means to “communicate concisely and reliably with colleagues, patients and insurers about screening for substance use and appropriate interventions,” according to the statement.

If physicians are reimbursed, use of the codes among members will be promoted, said Brian Whitman, a senior analyst for regulatory and insurer affairs with the American College of Physicians. The new codes are important because unlike with tobacco use screening and interventions, substance and alcohol use screening is less common and typically more time-consuming, he said in an interview.

“[Substance use screening] is a bit more specialized,” he said. “But to the extent that payers will accept them—and we hope they do—we would encourage members to use them,” he said of the codes.

The American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego. The codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Although Dr. William E. Golden, professor of medicine and public health at the University of Arkansas, Little Rock, said that he agrees with Dr. Ebbert that referral options are limited for those who screen positive, he noted that there is potential value in screening because “understanding patients' habits can alter primary care prescribing even if there are limited options for effective interventions.

Questions to ID Substance Abuse

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected your family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson professor and associate chair in the department of psychiatry and behavioral sciences at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

“My immediate response is that the government is putting the cart before the horse insofar as years of inadequate or no funding for drug treatment have left limited resources for physicians to refer to if patients screen positive,” said Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn. “Furthermore, I have concerns about the utility of 'brief interventions' for substance use and whether physicians who bill for these are adequately trained to deliver them.”

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis. “Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15–30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. According to the White House statement, they will enable efficient screening services for subtance abuse (see sidebar), and increase the likelihood of interventions. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The codes provide medical professionals a means to “communicate concisely and reliably with colleagues, patients and insurers about screening for substance use and appropriate interventions,” according to the statement.

If physicians are reimbursed, use of the codes among members will be promoted, said Brian Whitman, a senior analyst for regulatory and insurer affairs with the American College of Physicians. The new codes are important because unlike with tobacco use screening and interventions, substance and alcohol use screening is less common and typically more time-consuming, he said in an interview.

“[Substance use screening] is a bit more specialized,” he said. “But to the extent that payers will accept them—and we hope they do—we would encourage members to use them,” he said of the codes.

The American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego. The codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Although Dr. William E. Golden, professor of medicine and public health at the University of Arkansas, Little Rock, said that he agrees with Dr. Ebbert that referral options are limited for those who screen positive, he noted that there is potential value in screening because “understanding patients' habits can alter primary care prescribing even if there are limited options for effective interventions.

Questions to ID Substance Abuse

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected your family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson professor and associate chair in the department of psychiatry and behavioral sciences at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

“My immediate response is that the government is putting the cart before the horse insofar as years of inadequate or no funding for drug treatment have left limited resources for physicians to refer to if patients screen positive,” said Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn. “Furthermore, I have concerns about the utility of 'brief interventions' for substance use and whether physicians who bill for these are adequately trained to deliver them.”

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis. “Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15–30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. According to the White House statement, they will enable efficient screening services for subtance abuse (see sidebar), and increase the likelihood of interventions. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The codes provide medical professionals a means to “communicate concisely and reliably with colleagues, patients and insurers about screening for substance use and appropriate interventions,” according to the statement.

If physicians are reimbursed, use of the codes among members will be promoted, said Brian Whitman, a senior analyst for regulatory and insurer affairs with the American College of Physicians. The new codes are important because unlike with tobacco use screening and interventions, substance and alcohol use screening is less common and typically more time-consuming, he said in an interview.

“[Substance use screening] is a bit more specialized,” he said. “But to the extent that payers will accept them—and we hope they do—we would encourage members to use them,” he said of the codes.

The American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego. The codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Although Dr. William E. Golden, professor of medicine and public health at the University of Arkansas, Little Rock, said that he agrees with Dr. Ebbert that referral options are limited for those who screen positive, he noted that there is potential value in screening because “understanding patients' habits can alter primary care prescribing even if there are limited options for effective interventions.

Questions to ID Substance Abuse

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected your family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors stated in the report (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

"We encourage the rapid study of the efficacy and safety of [HPV-16/18] vaccines in males and, if successful, the recommendation of vaccination in young adult and adolescent males," they wrote.

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to women and girls would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Their recommendation is based on a number of factors. Data have confirmed an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers—particularly tonsil and base of tongue cancer—in those younger than 45 years.

In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

"The association is also quite strong with a significant risk of oropharyngeal cancer reported in epidemiologic case-control studies by numerous independent investigators and after adjustment for smoking and alcohol exposures," the authors wrote.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the "biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers," they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest that the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, they stated.

Lending further credence to this possibility is the reported increase in the frequency of oral sex in adolescents, which could be a contributing factor in the increase in HPV-associated oropharyngeal cancers in young adults.

Data from the Swedish Cancer Registry show that the prevalence of HPV-16 in oropharyngeal cancer specimens increased from 23% in the 1970s to 28% in the 1980s, 57% in the 1990s, and 68% in the 2000s, despite dramatic declines in smoking prevalence.

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors stated in the report (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

"We encourage the rapid study of the efficacy and safety of [HPV-16/18] vaccines in males and, if successful, the recommendation of vaccination in young adult and adolescent males," they wrote.

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to women and girls would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Their recommendation is based on a number of factors. Data have confirmed an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers—particularly tonsil and base of tongue cancer—in those younger than 45 years.

In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

"The association is also quite strong with a significant risk of oropharyngeal cancer reported in epidemiologic case-control studies by numerous independent investigators and after adjustment for smoking and alcohol exposures," the authors wrote.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the "biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers," they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest that the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, they stated.

Lending further credence to this possibility is the reported increase in the frequency of oral sex in adolescents, which could be a contributing factor in the increase in HPV-associated oropharyngeal cancers in young adults.

Data from the Swedish Cancer Registry show that the prevalence of HPV-16 in oropharyngeal cancer specimens increased from 23% in the 1970s to 28% in the 1980s, 57% in the 1990s, and 68% in the 2000s, despite dramatic declines in smoking prevalence.

Recent data linking human papillomavirus with oropharyngeal cancers, which typically occur in men, suggest a need for stepped-up efforts to gain approval for use of the HPV vaccine in young men and adolescent boys, according to Dr. Erich Sturgis and Dr. Paul M. Cinciripini, of the University of Texas M.D. Anderson Cancer Center, Houston.

Although the incidence of most types of squamous cell carcinomas of the head and neck have declined over the past 20 years, in tandem with declines in the prevalence of smoking, the incidence of oropharyngeal cancers has remained stagnant—a trend that may be attributable to the growing incidence of oncogenic HPV-associated cancers, the authors stated in the report (Cancer 2007 Oct. [doi:10.1002/cncr.22963]).

"We encourage the rapid study of the efficacy and safety of [HPV-16/18] vaccines in males and, if successful, the recommendation of vaccination in young adult and adolescent males," they wrote.

They praised efforts to promote the recently approved HPV-16/18 vaccination of young women and adolescent girls to reduce the incidence of cervical cancer and dysplasia, but warned that limiting vaccination programs to women and girls would delay potential benefits of preventing the HPV-16/18 oropharyngeal cancers in males.

Dr. Cinciripini has acted as a consultant for GlaxoSmithKline, the manufacturer of Cervarix, a vaccine against HPV 16/18.

Their recommendation is based on a number of factors. Data have confirmed an increase in the incidence of oral tongue cancer in young adults and of oropharyngeal cancers—particularly tonsil and base of tongue cancer—in those younger than 45 years.

In addition, the literature consistently shows a link between oncogenic HPV and oropharyngeal cancers, with HPV DNA being identified in about half of all oropharyngeal cancers and in a particularly high proportion of oropharyngeal cancers in nonsmokers. More than 90% of HPV-positive oropharyngeal cancers are a result of HPV-16.

"The association is also quite strong with a significant risk of oropharyngeal cancer reported in epidemiologic case-control studies by numerous independent investigators and after adjustment for smoking and alcohol exposures," the authors wrote.

The similarities between HPV-related oropharyngeal cancer and cervical carcinogenesis, and the "biologic plausibility of the HPV carcinogenesis model all support HPV causality of a proportion of oropharyngeal cancers," they noted.

The mode of transmission of HPV in patients with HPV-related oropharyngeal cancer is not clear, but some reports suggest that the sexual history of oncogenic HPV-positive oropharyngeal cancer patients mirrors that of women with cervical cancer, and it is likely that risk factors such as multiple sexual partners and oral-genital sex play a role, they stated.

Lending further credence to this possibility is the reported increase in the frequency of oral sex in adolescents, which could be a contributing factor in the increase in HPV-associated oropharyngeal cancers in young adults.

Data from the Swedish Cancer Registry show that the prevalence of HPV-16 in oropharyngeal cancer specimens increased from 23% in the 1970s to 28% in the 1980s, 57% in the 1990s, and 68% in the 2000s, despite dramatic declines in smoking prevalence.

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson Professor and associate chair in the department of psychiatry and behavioral services at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn., said years of either inadequate or no funding at all have left limited resources for physicians to refer to. In light of that, it seems that “the government is putting the cart before the horse” with the new codes, he said.

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis.

“Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15-30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. The ONDCP statement says the codes will enable efficient reporting of screening services for drug and alcohol abuse (see box below), and increase the likelihood of appropriate interventions for those in need. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The American College of Physicians, which did not create the codes but was involved in evaluating the codes and developing the language, will encourage private insurers to reimburse for the codes, Brian Whitman, a senior analyst for regulatory and insurer affairs with the ACP said in an interview.

Similarly, the American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego.

“This challenges most health professionals to give utmost attention to this problem.”

Additionally, the codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Sample Questions From the DAST

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected you family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson Professor and associate chair in the department of psychiatry and behavioral services at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn., said years of either inadequate or no funding at all have left limited resources for physicians to refer to. In light of that, it seems that “the government is putting the cart before the horse” with the new codes, he said.

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis.

“Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15-30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. The ONDCP statement says the codes will enable efficient reporting of screening services for drug and alcohol abuse (see box below), and increase the likelihood of appropriate interventions for those in need. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The American College of Physicians, which did not create the codes but was involved in evaluating the codes and developing the language, will encourage private insurers to reimburse for the codes, Brian Whitman, a senior analyst for regulatory and insurer affairs with the ACP said in an interview.

Similarly, the American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego.

“This challenges most health professionals to give utmost attention to this problem.”

Additionally, the codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Sample Questions From the DAST

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected you family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will “strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system,” according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

“The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit,” said Dr. David Spiegel, Willson Professor and associate chair in the department of psychiatry and behavioral services at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of “brief interventions” for substance use.

Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn., said years of either inadequate or no funding at all have left limited resources for physicians to refer to. In light of that, it seems that “the government is putting the cart before the horse” with the new codes, he said.

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

“We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management,” said Dr. Beecher, also an adjunct professor of psychiatry at the University of Minnesota, Minneapolis.

“Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity].”

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions “will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'”

The new codes (99408 for interactions of 15-30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. The ONDCP statement says the codes will enable efficient reporting of screening services for drug and alcohol abuse (see box below), and increase the likelihood of appropriate interventions for those in need. Similar codes for tobacco use screening and intervention previously were instituted, thus tobacco use screening and cessation counseling are excluded in these codes.

The American College of Physicians, which did not create the codes but was involved in evaluating the codes and developing the language, will encourage private insurers to reimburse for the codes, Brian Whitman, a senior analyst for regulatory and insurer affairs with the ACP said in an interview.

Similarly, the American Academy of Family Physicians will be “watching closely to see what payers will do,” Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

“They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective,” said Dr. Rodrigo A. Muñoz, of the University of California, San Diego.

“This challenges most health professionals to give utmost attention to this problem.”

Additionally, the codes are a reminder that substance abuse problems are “common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties,” he said.

Sample Questions From the DAST

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

▸ Can you get through the week without using drugs?

▸ Are you always able to stop using drugs when you want to?

▸ Do you ever feel bad or guilty about your drug use?

▸ Have you neglected you family because of your use of drugs?

▸ Have you been in trouble at work because of your use of drugs?

▸ Have you engaged in illegal activities in order to obtain drugs?

▸ Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

▸ Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

ORLANDO — Vascular structures visualized on dermoscopy aid in the diagnosis of both benign and malignant nonpigmented tumors of the skin, Dr. Brian Katz said at the annual meeting of the Florida Society of Dermatologic Surgeons.

In fact, associated vasculature should be evaluated carefully to avoid missing a malignancy, said Dr. Katz of Mount Sinai Medical Center, Miami Beach.

When using conventional dermoscopy for nonpigmented lesions, be careful about the amount of pressure applied because a blanching of the vessels can occur and impede diagnostic efforts. Also, consider using ultrasound gel rather than alcohol with dermoscopy, he suggested, because it helps prevent compression of vessels. (See box at right.)

This is important because special morphologic types of vessels are associated with different skin tumors. Various studies show which types of vessels are suggestive of which diagnoses, he said.

In nonpigmented basal cell carcinomas, arborizing vessels are a major feature visualized on dermoscopy, and these were shown in at least one study to have a 90% positive predictive value for basal cell carcinoma. Pink-white to white shiny areas and ulceration also are characteristic in these lesions.

With superficial basal cell carcinoma, two main dermoscopic features typically are observed: shiny pink to white structureless areas and short, fine telangiectasias.

Dr. Katz discussed other types of malignant lesions, along with their associated vasculature on dermoscopy:

PISquamous cell carcinoma in situ/Bowen's disease. These lesions are characterized by glomerular vessels and scaly surface on dermoscopy.

PISquamous cell carcinoma (more invasive types). Characterized by polymorphous vessels, which are mainly glomerular or hairpin vessels and are irregularly distributed and which have a whitish halo.

PIAmelanotic melanoma. Characterized by the presence of mainly dotted and linear irregular polymorphous vessels or by hairpin polymorphous vessels with milky-red globules/areas and ulceration. A whitish-pink background also may be seen on dermoscopy.

A rule of thumb is the more vessels seen, the more likely it is to be a malignant lesion, Dr. Katz said.

Vasculature visualized on dermoscopy is helpful for diagnosing benign nonpigmented lesions, including pyogenic granuloma (characterized by milky red homogenous areas separated with white intersecting lines with a white collarette at the periphery) and intradermal nevi (commalike vessels with a regular distribution throughout the lesion, a pink or pale structureless background, and sometimes pigmentary remnants).

Nonpigmented seborrheic keratosis also can be diagnosed with dermoscopy. It is characterized vascularly by regularly distributed hairpin loop vessels; dermoscopic features of keratinization; and dermoscopic features including comedolike opening, milialike cysts, sharp borders, fissures, and ridges. Yellow scaling and whitish halo also may be noted.

Other benign lesions that can be diagnosed include sebaceous hyperplasia—aggregated white to yellow central globularlike structures and surrounding, scarcely branching crown vessels at the periphery that never cross the center of the neoplasm—and Spitz nevus, which is characterized by dotted vessels, regular distribution, and a pink background, Dr. Katz said.

Dermoscopy of a malignant neoplasm reveals multiple arborizing vessels on a pink, whiteshiny background. Courtesy Dr. Brian Katz

Ultrasound Gel a Better Choice in Some Situations

Research on the use of dermoscopy has shown that although alcohol is the "best all around" fluid to use for dermoscopy, ultrasound gel is a better option in some instances, Dr. Katz noted.

For examining melanonychia of the nail plate, gel works best. Similarly, for nonpigmented tumors of the skin, in which visualization of the vasculature is important for making a correct diagnosis, gel helps mitigate the effects of some of the pressure that is applied with conventional contact dermoscopy.

In a comparison of contact dermoscopy with gel versus alcohol for a malignant melanoma, the gel clearly allowed much better visualization of the vasculature, while the alcohol allowed more compression—and thus blanching—of the vessels, he said.

The effect was strictly caused by the pressure applied, he said at the meeting, noting that pressure should be minimal with contact dermoscopy.

An option to circumvent this problem altogether is to use a polarized dermatoscope in noncontact mode, which has been shown to be the best option for visualizing blood vessels, Dr. Katz said.

Dermoscopy with ultrasound gel (left) allows for better visualization than with alcohol (right) because there is less vessel compression. PHOTOS COURTESY DR. HAROLD RABINOVITZ

A single dose of trivalent live attenuated intranasal influenza vaccine administered to children during a 2003–2004 influenza outbreak was well tolerated and efficacious despite antigenic differences in the vaccine strain and the dominant circulating virus, researchers reported.

This finding from an open-label, nonrandomized, community-based trial in children aged 5–18 years suggests trivalent live attenuated influenza vaccine (LAIV-T) protects against influenza via both innate and adaptive immune mechanisms, Dr. Pedro A. Piedra of Baylor College of Medicine, Houston, and his colleagues hypothesized.

Between Oct. 10 and Dec. 30, 2003—the first year the vaccine was licensed for use in the United States in healthy 5- to 49-year-olds—one dose of LAIV-T was administered by nasal spray to 6,569 age-eligible, healthy children, and one dose of trivalent inactivated influenza vaccine was administered by intramuscular injection to 1,040 children with underlying health conditions that increased influenza risks. A second vaccine dose was offered 4–6 weeks later in those under age 9 years receiving the vaccine for the first time, but most did not receive a second dose.

The vaccines were administered as part of a vaccination campaign that resulted in coverage of more than 30% in those aged 5–18 years in the intervention communities, the investigators noted (Pediatrics 2007; 120:e553–64; doi 10.1542/peds.2006-2836).

The influenza outbreak, which arrived early that year and coincided with the campaign, allowed investigators to evaluate both direct and indirect effectiveness of vaccination of school-age children during an outbreak. In addition, the dominant influenza virus during that outbreak was a significant antigenic variant—A/Fujian/411/2002 (H3N2)—that was distinct from the vaccine virus—A/Panama/2007/99 (H3N2).

Surveillance in the intervention communities and nearby comparison communities showed that live vaccine recipients developed significant protection against influenza-positive illness (37% vaccine effectiveness) and pneumonia and influenza events (50% overall vaccine effectiveness, 80% effectiveness in those aged 5–9 years).

Those who received the inactivated vaccine did not develop protection, but a number of possible causes for this are outlined, including the fact that most of the children were unable to receive the second vaccine dose during the outbreak period, and because the intervention and reference groups were not particularly well matched.

Furthermore, indirect effectiveness (herd protection) against medically attended acute respiratory illness was noted in nonparticipating children ages 5–11 years (13% reduction in events), and in nonparticipating adults ages 35–44 years (9% reduction in events). Such herd protection resulting from the vaccination of school-age children has been demonstrated in other studies, and is the basis for current consideration of universal influenza vaccination of school-age children as a complementary strategy to that currently advocated by the Advisory Committee on Immunization Prevention (ACIP) of the Centers for Disease Control and Prevention, Dr. Piedra and his colleagues noted.

The current strategy of vaccine prioritization based on risk for serious influenza-associated complications has resulted in a modest reduction in influenza-related morbidity and mortality, but has failed to control epidemics, they explained.

The investigators added that mathematical models and prior studies suggest that universal vaccination of school-age children—who have high rates of infection, medically attended illness, and hospitalization from influenza, and who “play an important role in the transmission of influenza within families, schools, and communities”—could play an important role in reducing overall influenza-related morbidity and mortality.

In the current study, herd protection was demonstrated in older individuals, who can be particularly susceptible to morbidity and mortality associated with influenza. However, this finding may have been biased by the significantly lower rates of medically attended acute respiratory illness in this population both before and after vaccination in the intervention communities, which is suggestive of a healthier adult population in the intervention communities, Dr. Piedra and his associates noted.

A single dose of trivalent live attenuated intranasal influenza vaccine administered to children during a 2003–2004 influenza outbreak was well tolerated and efficacious despite antigenic differences in the vaccine strain and the dominant circulating virus, researchers reported.

This finding from an open-label, nonrandomized, community-based trial in children aged 5–18 years suggests trivalent live attenuated influenza vaccine (LAIV-T) protects against influenza via both innate and adaptive immune mechanisms, Dr. Pedro A. Piedra of Baylor College of Medicine, Houston, and his colleagues hypothesized.

Between Oct. 10 and Dec. 30, 2003—the first year the vaccine was licensed for use in the United States in healthy 5- to 49-year-olds—one dose of LAIV-T was administered by nasal spray to 6,569 age-eligible, healthy children, and one dose of trivalent inactivated influenza vaccine was administered by intramuscular injection to 1,040 children with underlying health conditions that increased influenza risks. A second vaccine dose was offered 4–6 weeks later in those under age 9 years receiving the vaccine for the first time, but most did not receive a second dose.

The vaccines were administered as part of a vaccination campaign that resulted in coverage of more than 30% in those aged 5–18 years in the intervention communities, the investigators noted (Pediatrics 2007; 120:e553–64; doi 10.1542/peds.2006-2836).

The influenza outbreak, which arrived early that year and coincided with the campaign, allowed investigators to evaluate both direct and indirect effectiveness of vaccination of school-age children during an outbreak. In addition, the dominant influenza virus during that outbreak was a significant antigenic variant—A/Fujian/411/2002 (H3N2)—that was distinct from the vaccine virus—A/Panama/2007/99 (H3N2).

Surveillance in the intervention communities and nearby comparison communities showed that live vaccine recipients developed significant protection against influenza-positive illness (37% vaccine effectiveness) and pneumonia and influenza events (50% overall vaccine effectiveness, 80% effectiveness in those aged 5–9 years).

Those who received the inactivated vaccine did not develop protection, but a number of possible causes for this are outlined, including the fact that most of the children were unable to receive the second vaccine dose during the outbreak period, and because the intervention and reference groups were not particularly well matched.

Furthermore, indirect effectiveness (herd protection) against medically attended acute respiratory illness was noted in nonparticipating children ages 5–11 years (13% reduction in events), and in nonparticipating adults ages 35–44 years (9% reduction in events). Such herd protection resulting from the vaccination of school-age children has been demonstrated in other studies, and is the basis for current consideration of universal influenza vaccination of school-age children as a complementary strategy to that currently advocated by the Advisory Committee on Immunization Prevention (ACIP) of the Centers for Disease Control and Prevention, Dr. Piedra and his colleagues noted.

The current strategy of vaccine prioritization based on risk for serious influenza-associated complications has resulted in a modest reduction in influenza-related morbidity and mortality, but has failed to control epidemics, they explained.

The investigators added that mathematical models and prior studies suggest that universal vaccination of school-age children—who have high rates of infection, medically attended illness, and hospitalization from influenza, and who “play an important role in the transmission of influenza within families, schools, and communities”—could play an important role in reducing overall influenza-related morbidity and mortality.

In the current study, herd protection was demonstrated in older individuals, who can be particularly susceptible to morbidity and mortality associated with influenza. However, this finding may have been biased by the significantly lower rates of medically attended acute respiratory illness in this population both before and after vaccination in the intervention communities, which is suggestive of a healthier adult population in the intervention communities, Dr. Piedra and his associates noted.

A single dose of trivalent live attenuated intranasal influenza vaccine administered to children during a 2003–2004 influenza outbreak was well tolerated and efficacious despite antigenic differences in the vaccine strain and the dominant circulating virus, researchers reported.

This finding from an open-label, nonrandomized, community-based trial in children aged 5–18 years suggests trivalent live attenuated influenza vaccine (LAIV-T) protects against influenza via both innate and adaptive immune mechanisms, Dr. Pedro A. Piedra of Baylor College of Medicine, Houston, and his colleagues hypothesized.

Between Oct. 10 and Dec. 30, 2003—the first year the vaccine was licensed for use in the United States in healthy 5- to 49-year-olds—one dose of LAIV-T was administered by nasal spray to 6,569 age-eligible, healthy children, and one dose of trivalent inactivated influenza vaccine was administered by intramuscular injection to 1,040 children with underlying health conditions that increased influenza risks. A second vaccine dose was offered 4–6 weeks later in those under age 9 years receiving the vaccine for the first time, but most did not receive a second dose.

The vaccines were administered as part of a vaccination campaign that resulted in coverage of more than 30% in those aged 5–18 years in the intervention communities, the investigators noted (Pediatrics 2007; 120:e553–64; doi 10.1542/peds.2006-2836).

The influenza outbreak, which arrived early that year and coincided with the campaign, allowed investigators to evaluate both direct and indirect effectiveness of vaccination of school-age children during an outbreak. In addition, the dominant influenza virus during that outbreak was a significant antigenic variant—A/Fujian/411/2002 (H3N2)—that was distinct from the vaccine virus—A/Panama/2007/99 (H3N2).

Surveillance in the intervention communities and nearby comparison communities showed that live vaccine recipients developed significant protection against influenza-positive illness (37% vaccine effectiveness) and pneumonia and influenza events (50% overall vaccine effectiveness, 80% effectiveness in those aged 5–9 years).

Those who received the inactivated vaccine did not develop protection, but a number of possible causes for this are outlined, including the fact that most of the children were unable to receive the second vaccine dose during the outbreak period, and because the intervention and reference groups were not particularly well matched.

Furthermore, indirect effectiveness (herd protection) against medically attended acute respiratory illness was noted in nonparticipating children ages 5–11 years (13% reduction in events), and in nonparticipating adults ages 35–44 years (9% reduction in events). Such herd protection resulting from the vaccination of school-age children has been demonstrated in other studies, and is the basis for current consideration of universal influenza vaccination of school-age children as a complementary strategy to that currently advocated by the Advisory Committee on Immunization Prevention (ACIP) of the Centers for Disease Control and Prevention, Dr. Piedra and his colleagues noted.

The current strategy of vaccine prioritization based on risk for serious influenza-associated complications has resulted in a modest reduction in influenza-related morbidity and mortality, but has failed to control epidemics, they explained.

The investigators added that mathematical models and prior studies suggest that universal vaccination of school-age children—who have high rates of infection, medically attended illness, and hospitalization from influenza, and who “play an important role in the transmission of influenza within families, schools, and communities”—could play an important role in reducing overall influenza-related morbidity and mortality.

In the current study, herd protection was demonstrated in older individuals, who can be particularly susceptible to morbidity and mortality associated with influenza. However, this finding may have been biased by the significantly lower rates of medically attended acute respiratory illness in this population both before and after vaccination in the intervention communities, which is suggestive of a healthier adult population in the intervention communities, Dr. Piedra and his associates noted.