Barbara J. Rutledge

The increased lymphoma risk seen in patients with severe rheumatoid arthritis appears to involve a specific subtype of diffuse large B-cell lymphoma that arises from activated peripheral blood B cells.

Dr. Eva Baecklund of Akademiska Hospital in Uppsala, Sweden, and her associates identified 139 RA patients with diffuse large B-cell lymphoma from within a population-based case-control study of 378 RA patients with lymphoma. The RA patients with lymphoma were originally identified from linkage of the nationwide Swedish Inpatient Register with the Swedish Cancer Register.

Diffuse large B-cell lymphoma (DLBCL) can be classified into two major subtypes based on gene expression profiles. One tumor subtype expresses genes characteristic of germinal center (GC) B cells. The other tumor subtype (non-GC) expresses genes seen in activated peripheral blood B cells.

In this study, the cases of DLBCL were classified as GC or non-GC based on immunohistochemistry using a three-marker system. CD10, Bcl-6, and interferon regulatory factor 4 (IRF-4, also known as multiple myeloma oncogene 1) were tested. Staining of 30% or more of tumor cells was defined as positive.

Investigators reviewed the original slides and paraffin-embedded lymphoma tissues from pathology laboratories and reclassified the tumors according to the World Health Organization classification system. Immunohistochemical staining for CD10, Bcl-6, and IRF-4 antibodies was performed on paraffin-imbedded tissue. Gene expression profiling could not be performed because of the lack of frozen tissue.

All tumors that stained positive for CD10, whether positive or negative for Bcl-6, were classified as GC-like. Tumors that stained negative for both CD10 and Bcl-6 were classified as non-GC-like. Tumors that showed negative staining for CD10 but positive staining for Bcl-6 were tested for IRF-4. CD10-negative/Bcl-6-positive tumor cells that showed positive staining for IRF-4 were classified as non-GC subtype, and those that showed negative IRF-4 staining were classified as GC subtype.

DLBCL tumors from 42 patients (30%) were identified as GC subtype, and DLBCL tumors from 97 patients (70%) were identified as non-GC subtype. Women were the majority in both the GC and non-GC groups (57% and 60%, respectively). The mean age of RA onset was around 50 years in each group. The mean age at lymphoma diagnosis was 70 years (range: 32–84 years) for patients with GC subtype DLBCL, compared with 71 years (range: 48–89) for patients with non-GC subtype DLBCL.

There were no significant differences between the two groups in RA functional class, disease activity, or RA treatment. Compared with patients with GC subtype DLBCL tumors, a higher proportion of patients with non-GC subtype DLBCL tumors had RA disease activity in functional classes III and IV, but the trend did not reach statistical significance (P = .07).

Tumor stage differed significantly in patients with non-GC subtype tumors, compared with those with GC subtype tumors (P = .005). A higher proportion of patients with non-GC subtype DLBCL tumors (60 patients; 64%) had disseminated lymphoma (Ann Arbor stage IV), compared with patients with GC DLBCL tumors (15 patients; 38%). Among patients in whom extranodal involvement could be assessed, significantly more patients with non-GC DLCBL tumors (72/93; 77%) had extranodal involvement, compared with patients with GC DLCBL tumors (25/39; 64%; P = .03).

In RA patients with advanced lymphoma, the prognosis was worse if the tumor subtype was non-GC.

The 5-year overall survival was 33% for patients with GC-subtype DLCBL tumors, compared with 16% for patients with non-GC subtype DLCBL tumors, the investigators wrote (Arthritis Rheum. 2006;12:3774–81).

The increased lymphoma risk seen in patients with severe rheumatoid arthritis appears to involve a specific subtype of diffuse large B-cell lymphoma that arises from activated peripheral blood B cells.

Dr. Eva Baecklund of Akademiska Hospital in Uppsala, Sweden, and her associates identified 139 RA patients with diffuse large B-cell lymphoma from within a population-based case-control study of 378 RA patients with lymphoma. The RA patients with lymphoma were originally identified from linkage of the nationwide Swedish Inpatient Register with the Swedish Cancer Register.

Diffuse large B-cell lymphoma (DLBCL) can be classified into two major subtypes based on gene expression profiles. One tumor subtype expresses genes characteristic of germinal center (GC) B cells. The other tumor subtype (non-GC) expresses genes seen in activated peripheral blood B cells.

In this study, the cases of DLBCL were classified as GC or non-GC based on immunohistochemistry using a three-marker system. CD10, Bcl-6, and interferon regulatory factor 4 (IRF-4, also known as multiple myeloma oncogene 1) were tested. Staining of 30% or more of tumor cells was defined as positive.

Investigators reviewed the original slides and paraffin-embedded lymphoma tissues from pathology laboratories and reclassified the tumors according to the World Health Organization classification system. Immunohistochemical staining for CD10, Bcl-6, and IRF-4 antibodies was performed on paraffin-imbedded tissue. Gene expression profiling could not be performed because of the lack of frozen tissue.

All tumors that stained positive for CD10, whether positive or negative for Bcl-6, were classified as GC-like. Tumors that stained negative for both CD10 and Bcl-6 were classified as non-GC-like. Tumors that showed negative staining for CD10 but positive staining for Bcl-6 were tested for IRF-4. CD10-negative/Bcl-6-positive tumor cells that showed positive staining for IRF-4 were classified as non-GC subtype, and those that showed negative IRF-4 staining were classified as GC subtype.

DLBCL tumors from 42 patients (30%) were identified as GC subtype, and DLBCL tumors from 97 patients (70%) were identified as non-GC subtype. Women were the majority in both the GC and non-GC groups (57% and 60%, respectively). The mean age of RA onset was around 50 years in each group. The mean age at lymphoma diagnosis was 70 years (range: 32–84 years) for patients with GC subtype DLBCL, compared with 71 years (range: 48–89) for patients with non-GC subtype DLBCL.

There were no significant differences between the two groups in RA functional class, disease activity, or RA treatment. Compared with patients with GC subtype DLBCL tumors, a higher proportion of patients with non-GC subtype DLBCL tumors had RA disease activity in functional classes III and IV, but the trend did not reach statistical significance (P = .07).

Tumor stage differed significantly in patients with non-GC subtype tumors, compared with those with GC subtype tumors (P = .005). A higher proportion of patients with non-GC subtype DLBCL tumors (60 patients; 64%) had disseminated lymphoma (Ann Arbor stage IV), compared with patients with GC DLBCL tumors (15 patients; 38%). Among patients in whom extranodal involvement could be assessed, significantly more patients with non-GC DLCBL tumors (72/93; 77%) had extranodal involvement, compared with patients with GC DLCBL tumors (25/39; 64%; P = .03).

In RA patients with advanced lymphoma, the prognosis was worse if the tumor subtype was non-GC.

The 5-year overall survival was 33% for patients with GC-subtype DLCBL tumors, compared with 16% for patients with non-GC subtype DLCBL tumors, the investigators wrote (Arthritis Rheum. 2006;12:3774–81).

The increased lymphoma risk seen in patients with severe rheumatoid arthritis appears to involve a specific subtype of diffuse large B-cell lymphoma that arises from activated peripheral blood B cells.

Dr. Eva Baecklund of Akademiska Hospital in Uppsala, Sweden, and her associates identified 139 RA patients with diffuse large B-cell lymphoma from within a population-based case-control study of 378 RA patients with lymphoma. The RA patients with lymphoma were originally identified from linkage of the nationwide Swedish Inpatient Register with the Swedish Cancer Register.

Diffuse large B-cell lymphoma (DLBCL) can be classified into two major subtypes based on gene expression profiles. One tumor subtype expresses genes characteristic of germinal center (GC) B cells. The other tumor subtype (non-GC) expresses genes seen in activated peripheral blood B cells.

In this study, the cases of DLBCL were classified as GC or non-GC based on immunohistochemistry using a three-marker system. CD10, Bcl-6, and interferon regulatory factor 4 (IRF-4, also known as multiple myeloma oncogene 1) were tested. Staining of 30% or more of tumor cells was defined as positive.

Investigators reviewed the original slides and paraffin-embedded lymphoma tissues from pathology laboratories and reclassified the tumors according to the World Health Organization classification system. Immunohistochemical staining for CD10, Bcl-6, and IRF-4 antibodies was performed on paraffin-imbedded tissue. Gene expression profiling could not be performed because of the lack of frozen tissue.

All tumors that stained positive for CD10, whether positive or negative for Bcl-6, were classified as GC-like. Tumors that stained negative for both CD10 and Bcl-6 were classified as non-GC-like. Tumors that showed negative staining for CD10 but positive staining for Bcl-6 were tested for IRF-4. CD10-negative/Bcl-6-positive tumor cells that showed positive staining for IRF-4 were classified as non-GC subtype, and those that showed negative IRF-4 staining were classified as GC subtype.

DLBCL tumors from 42 patients (30%) were identified as GC subtype, and DLBCL tumors from 97 patients (70%) were identified as non-GC subtype. Women were the majority in both the GC and non-GC groups (57% and 60%, respectively). The mean age of RA onset was around 50 years in each group. The mean age at lymphoma diagnosis was 70 years (range: 32–84 years) for patients with GC subtype DLBCL, compared with 71 years (range: 48–89) for patients with non-GC subtype DLBCL.

There were no significant differences between the two groups in RA functional class, disease activity, or RA treatment. Compared with patients with GC subtype DLBCL tumors, a higher proportion of patients with non-GC subtype DLBCL tumors had RA disease activity in functional classes III and IV, but the trend did not reach statistical significance (P = .07).

Tumor stage differed significantly in patients with non-GC subtype tumors, compared with those with GC subtype tumors (P = .005). A higher proportion of patients with non-GC subtype DLBCL tumors (60 patients; 64%) had disseminated lymphoma (Ann Arbor stage IV), compared with patients with GC DLBCL tumors (15 patients; 38%). Among patients in whom extranodal involvement could be assessed, significantly more patients with non-GC DLCBL tumors (72/93; 77%) had extranodal involvement, compared with patients with GC DLCBL tumors (25/39; 64%; P = .03).

In RA patients with advanced lymphoma, the prognosis was worse if the tumor subtype was non-GC.

The 5-year overall survival was 33% for patients with GC-subtype DLCBL tumors, compared with 16% for patients with non-GC subtype DLCBL tumors, the investigators wrote (Arthritis Rheum. 2006;12:3774–81).

Methicillin-resistant Staphylococcus aureus (MRSA) strains that typically cause community-acquired infections are infecting patients in hospitals, and strains considered health care associated are infecting patients with no health care-related risk factors, reported Dr. R. Monina Klevens of the Centers for Disease Control and Prevention (CDC) and her associates.

The Active Bacterial Core Surveillance program of the CDC is a population-based surveillance system for invasive organisms, including MRSA infections. The surveillance is ongoing in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee (Emerging Infectious Diseases 2006;12:1991–3).

Surveillance reports are generated when positive MRSA cultures are detected in normally sterile sites, such as blood or cerebrospinal fluid.

Laboratory reports are linked to the patient's medical record, and health care-related risk factors (HRFs) are abstracted from the medical record for inclusion in a surveillance database.

HRFs include the presence of an invasive device, history of MRSA infection or colonization, dialysis, hospitalization, residence in a long-term care facility, and surgery.

Obtaining a bacterial culture more than 48 hours after hospital admission also suggests infection with a health care-associated strain.

MRSA strains are empirically typed, based on the separation characteristics seen using pulsed-field gel electrophoresis. In earlier MRSA outbreaks, strains USA300 and USA400 were the predominant community-associated strains. USA100 and USA 500 were considered health care-associated strains.

From January 2004 through February 2006, more than 9,100 cases of invasive MRSA were reported and classified as classic health care-associated infections, with cultures obtained more than 48 hours after admission; cases with one or more HRF but with community-onset infections (less than 48 hours); or cases with community-associated infections and no HRF.

Of the 9,147 cases, 2,535 (28%) were classic health care-associated infections, 5,353 (59%) were health care associated, but community acquired, and 1,259 (14%) were community-associated infections.

One hundred isolates were selected for typing by pulsed-field gel electrophoresis. Seven of 27 isolates (26%) from community-associated cases were USA100 or USA500, and 8 of 29 (28%) classic health care-associated cases were strain USA300. Overall, 18%–28% of patients with HRFs were infected with strains considered to be community-associated MRSA strains.

“The distinction between health care- and community-associated MRSA is rapidly blurring,” Dr. Klevens and her associates wrote.

Methicillin-resistant Staphylococcus aureus (MRSA) strains that typically cause community-acquired infections are infecting patients in hospitals, and strains considered health care associated are infecting patients with no health care-related risk factors, reported Dr. R. Monina Klevens of the Centers for Disease Control and Prevention (CDC) and her associates.

The Active Bacterial Core Surveillance program of the CDC is a population-based surveillance system for invasive organisms, including MRSA infections. The surveillance is ongoing in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee (Emerging Infectious Diseases 2006;12:1991–3).

Surveillance reports are generated when positive MRSA cultures are detected in normally sterile sites, such as blood or cerebrospinal fluid.

Laboratory reports are linked to the patient's medical record, and health care-related risk factors (HRFs) are abstracted from the medical record for inclusion in a surveillance database.

HRFs include the presence of an invasive device, history of MRSA infection or colonization, dialysis, hospitalization, residence in a long-term care facility, and surgery.

Obtaining a bacterial culture more than 48 hours after hospital admission also suggests infection with a health care-associated strain.

MRSA strains are empirically typed, based on the separation characteristics seen using pulsed-field gel electrophoresis. In earlier MRSA outbreaks, strains USA300 and USA400 were the predominant community-associated strains. USA100 and USA 500 were considered health care-associated strains.

From January 2004 through February 2006, more than 9,100 cases of invasive MRSA were reported and classified as classic health care-associated infections, with cultures obtained more than 48 hours after admission; cases with one or more HRF but with community-onset infections (less than 48 hours); or cases with community-associated infections and no HRF.

Of the 9,147 cases, 2,535 (28%) were classic health care-associated infections, 5,353 (59%) were health care associated, but community acquired, and 1,259 (14%) were community-associated infections.

One hundred isolates were selected for typing by pulsed-field gel electrophoresis. Seven of 27 isolates (26%) from community-associated cases were USA100 or USA500, and 8 of 29 (28%) classic health care-associated cases were strain USA300. Overall, 18%–28% of patients with HRFs were infected with strains considered to be community-associated MRSA strains.

“The distinction between health care- and community-associated MRSA is rapidly blurring,” Dr. Klevens and her associates wrote.

Methicillin-resistant Staphylococcus aureus (MRSA) strains that typically cause community-acquired infections are infecting patients in hospitals, and strains considered health care associated are infecting patients with no health care-related risk factors, reported Dr. R. Monina Klevens of the Centers for Disease Control and Prevention (CDC) and her associates.

The Active Bacterial Core Surveillance program of the CDC is a population-based surveillance system for invasive organisms, including MRSA infections. The surveillance is ongoing in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee (Emerging Infectious Diseases 2006;12:1991–3).

Surveillance reports are generated when positive MRSA cultures are detected in normally sterile sites, such as blood or cerebrospinal fluid.

Laboratory reports are linked to the patient's medical record, and health care-related risk factors (HRFs) are abstracted from the medical record for inclusion in a surveillance database.

HRFs include the presence of an invasive device, history of MRSA infection or colonization, dialysis, hospitalization, residence in a long-term care facility, and surgery.

Obtaining a bacterial culture more than 48 hours after hospital admission also suggests infection with a health care-associated strain.

MRSA strains are empirically typed, based on the separation characteristics seen using pulsed-field gel electrophoresis. In earlier MRSA outbreaks, strains USA300 and USA400 were the predominant community-associated strains. USA100 and USA 500 were considered health care-associated strains.

From January 2004 through February 2006, more than 9,100 cases of invasive MRSA were reported and classified as classic health care-associated infections, with cultures obtained more than 48 hours after admission; cases with one or more HRF but with community-onset infections (less than 48 hours); or cases with community-associated infections and no HRF.

Of the 9,147 cases, 2,535 (28%) were classic health care-associated infections, 5,353 (59%) were health care associated, but community acquired, and 1,259 (14%) were community-associated infections.

One hundred isolates were selected for typing by pulsed-field gel electrophoresis. Seven of 27 isolates (26%) from community-associated cases were USA100 or USA500, and 8 of 29 (28%) classic health care-associated cases were strain USA300. Overall, 18%–28% of patients with HRFs were infected with strains considered to be community-associated MRSA strains.

“The distinction between health care- and community-associated MRSA is rapidly blurring,” Dr. Klevens and her associates wrote.

MENDOZA, ARGENTINA – Physicians with addictions to alcohol, drugs, or gambling–or those charged with sexual misconduct–generally do well in overcoming their problems with good treatment, Dr. Gregory Collins reported at the Sixth World Congress on Depressive Disorders.

But treating colleagues is particularly challenging, partly because often they are initially defensive and hostile.

“The doctor typically blames someone else,” said Dr. Collins, who is head of the Alcohol and Drug Recovery Center at The Cleveland Clinic Foundation.

“A big problem is the sense of entitlement or narcissism.”

The success of treatment hinges on the impaired physician's serious self-examination and recognition of mistakes. It is imperative that the physician agree to accept help and comply with monitoring, Dr. Collins said.

“Eventually, when they figure out that they really are in trouble, they have a sense of overwhelming guilt and shame,” Dr. Collins said.

Suicide can be a major risk under those circumstances.

Of course, an arrest or even an accusation of impairment can be as damaging to the doctor's career as a conviction, Dr. Collins said. In these cases, a report is filed with licensing boards, and the incident becomes part of the public record.

An arrest might be given prominent coverage, but exoneration might not be considered as newsworthy. The negative publicity alone in such cases can cause permanent damage to the doctor's career, even if the physician is later found innocent.

Impaired physicians often are extremely talented, creative, and intelligent individuals who are successful in their careers.

Narcissism can be a major factor underlying disruptive behavior, in which the doctor disregards all hospital rules.

“He is abusive, criticizes fellow employees, throws things in the operating room, curses people out, uses a lot of profanity, tells dirty jokes, makes racist remarks, parks in the handicapped space right next to the hospital, takes the president's parking space,” Dr. Collins said.

“Administratively, he becomes a problem, and workplace morale suffers.”

Risk factors for impairment include a family history of alcoholism or drug addiction.

Another risk factor is early exposure to alcohol or drugs, perhaps before entering graduate school or obtaining a professional degree.

Doctors who practice alone are at greater risk than are those in group practice, Dr. Collins said.

Many doctors have high stress levels and a “workaholic” schedule. Depression, frustration, and exhaustion from overwork may lead to self-medication with alcohol or drugs.

The process of investigating a doctor for substance abuse is usually triggered by a negative event such as a prescription irregularity or a bad surgical outcome that casts suspicion on the doctor.

Some states, such as Ohio, have laws requiring physicians to report doctors who are suspected of impairment.

According to Dr. Collins, rehabilitation attempts to stop what he referred to as the BEAT Pathology: the harmful Behavior, consisting of alcohol or drug abuse; negative Emotions such as resentment, anger, and depression associated with being in treatment; Attitudes of superiority, dishonesty, and paranoia; and “sick” Thinking, based on denial of the situation and focusing on revenge, self-pity, and manipulation.

After the physician has been sober for 2 years, credibility is usually restored. Doctors are usually monitored for 5 years after they return to their practices, Dr. Collins said.

Ninety percent of physicians do recover after treatment.

“They are our best treatment-outcome group,” Dr. Collins said.

MENDOZA, ARGENTINA – Physicians with addictions to alcohol, drugs, or gambling–or those charged with sexual misconduct–generally do well in overcoming their problems with good treatment, Dr. Gregory Collins reported at the Sixth World Congress on Depressive Disorders.

But treating colleagues is particularly challenging, partly because often they are initially defensive and hostile.

“The doctor typically blames someone else,” said Dr. Collins, who is head of the Alcohol and Drug Recovery Center at The Cleveland Clinic Foundation.

“A big problem is the sense of entitlement or narcissism.”

The success of treatment hinges on the impaired physician's serious self-examination and recognition of mistakes. It is imperative that the physician agree to accept help and comply with monitoring, Dr. Collins said.

“Eventually, when they figure out that they really are in trouble, they have a sense of overwhelming guilt and shame,” Dr. Collins said.

Suicide can be a major risk under those circumstances.

Of course, an arrest or even an accusation of impairment can be as damaging to the doctor's career as a conviction, Dr. Collins said. In these cases, a report is filed with licensing boards, and the incident becomes part of the public record.

An arrest might be given prominent coverage, but exoneration might not be considered as newsworthy. The negative publicity alone in such cases can cause permanent damage to the doctor's career, even if the physician is later found innocent.

Impaired physicians often are extremely talented, creative, and intelligent individuals who are successful in their careers.

Narcissism can be a major factor underlying disruptive behavior, in which the doctor disregards all hospital rules.

“He is abusive, criticizes fellow employees, throws things in the operating room, curses people out, uses a lot of profanity, tells dirty jokes, makes racist remarks, parks in the handicapped space right next to the hospital, takes the president's parking space,” Dr. Collins said.

“Administratively, he becomes a problem, and workplace morale suffers.”

Risk factors for impairment include a family history of alcoholism or drug addiction.

Another risk factor is early exposure to alcohol or drugs, perhaps before entering graduate school or obtaining a professional degree.

Doctors who practice alone are at greater risk than are those in group practice, Dr. Collins said.

Many doctors have high stress levels and a “workaholic” schedule. Depression, frustration, and exhaustion from overwork may lead to self-medication with alcohol or drugs.

The process of investigating a doctor for substance abuse is usually triggered by a negative event such as a prescription irregularity or a bad surgical outcome that casts suspicion on the doctor.

Some states, such as Ohio, have laws requiring physicians to report doctors who are suspected of impairment.

According to Dr. Collins, rehabilitation attempts to stop what he referred to as the BEAT Pathology: the harmful Behavior, consisting of alcohol or drug abuse; negative Emotions such as resentment, anger, and depression associated with being in treatment; Attitudes of superiority, dishonesty, and paranoia; and “sick” Thinking, based on denial of the situation and focusing on revenge, self-pity, and manipulation.

After the physician has been sober for 2 years, credibility is usually restored. Doctors are usually monitored for 5 years after they return to their practices, Dr. Collins said.

Ninety percent of physicians do recover after treatment.

“They are our best treatment-outcome group,” Dr. Collins said.

MENDOZA, ARGENTINA – Physicians with addictions to alcohol, drugs, or gambling–or those charged with sexual misconduct–generally do well in overcoming their problems with good treatment, Dr. Gregory Collins reported at the Sixth World Congress on Depressive Disorders.

But treating colleagues is particularly challenging, partly because often they are initially defensive and hostile.

“The doctor typically blames someone else,” said Dr. Collins, who is head of the Alcohol and Drug Recovery Center at The Cleveland Clinic Foundation.

“A big problem is the sense of entitlement or narcissism.”

The success of treatment hinges on the impaired physician's serious self-examination and recognition of mistakes. It is imperative that the physician agree to accept help and comply with monitoring, Dr. Collins said.

“Eventually, when they figure out that they really are in trouble, they have a sense of overwhelming guilt and shame,” Dr. Collins said.

Suicide can be a major risk under those circumstances.

Of course, an arrest or even an accusation of impairment can be as damaging to the doctor's career as a conviction, Dr. Collins said. In these cases, a report is filed with licensing boards, and the incident becomes part of the public record.

An arrest might be given prominent coverage, but exoneration might not be considered as newsworthy. The negative publicity alone in such cases can cause permanent damage to the doctor's career, even if the physician is later found innocent.

Impaired physicians often are extremely talented, creative, and intelligent individuals who are successful in their careers.

Narcissism can be a major factor underlying disruptive behavior, in which the doctor disregards all hospital rules.

“He is abusive, criticizes fellow employees, throws things in the operating room, curses people out, uses a lot of profanity, tells dirty jokes, makes racist remarks, parks in the handicapped space right next to the hospital, takes the president's parking space,” Dr. Collins said.

“Administratively, he becomes a problem, and workplace morale suffers.”

Risk factors for impairment include a family history of alcoholism or drug addiction.

Another risk factor is early exposure to alcohol or drugs, perhaps before entering graduate school or obtaining a professional degree.

Doctors who practice alone are at greater risk than are those in group practice, Dr. Collins said.

Many doctors have high stress levels and a “workaholic” schedule. Depression, frustration, and exhaustion from overwork may lead to self-medication with alcohol or drugs.

The process of investigating a doctor for substance abuse is usually triggered by a negative event such as a prescription irregularity or a bad surgical outcome that casts suspicion on the doctor.

Some states, such as Ohio, have laws requiring physicians to report doctors who are suspected of impairment.

According to Dr. Collins, rehabilitation attempts to stop what he referred to as the BEAT Pathology: the harmful Behavior, consisting of alcohol or drug abuse; negative Emotions such as resentment, anger, and depression associated with being in treatment; Attitudes of superiority, dishonesty, and paranoia; and “sick” Thinking, based on denial of the situation and focusing on revenge, self-pity, and manipulation.

After the physician has been sober for 2 years, credibility is usually restored. Doctors are usually monitored for 5 years after they return to their practices, Dr. Collins said.

Ninety percent of physicians do recover after treatment.

“They are our best treatment-outcome group,” Dr. Collins said.

An Internet-based glucose monitoring system can be more effective than conventional diabetes care systems for the long-term control of blood glucose and maintenance of glucose stability in type 2 diabetes patients, according to Dr. Jae-Hyoung Cho and colleagues at the Catholic University of Korea, Seoul.

Eighty patients with type 2 diabetes participated in a 30-month study comparing glucose monitoring systems. The patients were randomly assigned to the intervention group, for treatment with Internet-based glucose monitoring, or to the control group, which received conventional monitoring (Diabetes Care 2006;29:2625–31).

At baseline, patients had a physical examination and standard laboratory tests, including measurement of hemoglobin A_1c. In a 4-hour diabetes management program, patients were taught daily self-monitoring of blood glucose to maintain glycemic control and were advised on nutrition and exercise. Every 3 months, they met with their physician and provided a blood sample for determination of HbA_1c level.

Patients in the intervention group logged onto a Web site each day to access an online chart on which they entered glucose levels from self-monitoring, and their weight, blood pressure, and medication use. They could post questions to clinical staff via a comments' box, and every 2 weeks, staff would send them recommendations. The control group patients kept conventional records of their blood glucose levels. They received recommendations from the same endocrinologists who worked online with the intervention group.

Mean baseline HbA_1c values were 7.5% in the control group and 7.7% in the intervention group. After 30 months, mean HbA_1c values were 7.5% and 6.9% in the control and intervention groups, respectively, a statistically significant difference.

An Internet-based glucose monitoring system can be more effective than conventional diabetes care systems for the long-term control of blood glucose and maintenance of glucose stability in type 2 diabetes patients, according to Dr. Jae-Hyoung Cho and colleagues at the Catholic University of Korea, Seoul.

Eighty patients with type 2 diabetes participated in a 30-month study comparing glucose monitoring systems. The patients were randomly assigned to the intervention group, for treatment with Internet-based glucose monitoring, or to the control group, which received conventional monitoring (Diabetes Care 2006;29:2625–31).

At baseline, patients had a physical examination and standard laboratory tests, including measurement of hemoglobin A_1c. In a 4-hour diabetes management program, patients were taught daily self-monitoring of blood glucose to maintain glycemic control and were advised on nutrition and exercise. Every 3 months, they met with their physician and provided a blood sample for determination of HbA_1c level.

Patients in the intervention group logged onto a Web site each day to access an online chart on which they entered glucose levels from self-monitoring, and their weight, blood pressure, and medication use. They could post questions to clinical staff via a comments' box, and every 2 weeks, staff would send them recommendations. The control group patients kept conventional records of their blood glucose levels. They received recommendations from the same endocrinologists who worked online with the intervention group.

Mean baseline HbA_1c values were 7.5% in the control group and 7.7% in the intervention group. After 30 months, mean HbA_1c values were 7.5% and 6.9% in the control and intervention groups, respectively, a statistically significant difference.

An Internet-based glucose monitoring system can be more effective than conventional diabetes care systems for the long-term control of blood glucose and maintenance of glucose stability in type 2 diabetes patients, according to Dr. Jae-Hyoung Cho and colleagues at the Catholic University of Korea, Seoul.

Eighty patients with type 2 diabetes participated in a 30-month study comparing glucose monitoring systems. The patients were randomly assigned to the intervention group, for treatment with Internet-based glucose monitoring, or to the control group, which received conventional monitoring (Diabetes Care 2006;29:2625–31).

At baseline, patients had a physical examination and standard laboratory tests, including measurement of hemoglobin A_1c. In a 4-hour diabetes management program, patients were taught daily self-monitoring of blood glucose to maintain glycemic control and were advised on nutrition and exercise. Every 3 months, they met with their physician and provided a blood sample for determination of HbA_1c level.

Patients in the intervention group logged onto a Web site each day to access an online chart on which they entered glucose levels from self-monitoring, and their weight, blood pressure, and medication use. They could post questions to clinical staff via a comments' box, and every 2 weeks, staff would send them recommendations. The control group patients kept conventional records of their blood glucose levels. They received recommendations from the same endocrinologists who worked online with the intervention group.

Mean baseline HbA_1c values were 7.5% in the control group and 7.7% in the intervention group. After 30 months, mean HbA_1c values were 7.5% and 6.9% in the control and intervention groups, respectively, a statistically significant difference.

BUENOS AIRES — Treatment of orthopedic injuries in patients with traumatic brain injury should not be delayed, Dr. Ivan Rubel said at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

A population-based study conducted in the Twin Cities area of Minnesota found that most patients who were seen in an emergency department for traumatic brain injury had received the injury from sports and recreational activities (Minn. Med. 2006;89:40–4). The traumatic brain injuries that trauma surgeons are more likely to encounter, however, come from falls or car accidents, said Dr. Rubel, director of the orthopedics and traumatology department at FLENI Institute in Buenos Aires.

Pelvic and extremity fractures are common in patients with traumatic brain injury. Many skeletal injuries are not given priority, or might even be missed. However, as the survival rate of patients with traumatic brain injury has increased, there is a greater emphasis on minimizing dysfunction and disability in these patients, particularly when the dysfunction and disability arise from concomitant orthopedic trauma.

In a study of health-related quality of life in pediatric patients during the first year following a traumatic brain injury, the treatment of associated injuries was shown to have a greater impact than other factors such as patient or family characteristics (Arch. Pediatr. Adolesc. Med. 2006;160:252–60). “With the recent advances in intensive care medicine, most of these patients survive,” said Dr. Rubel. “We have to focus on minimizing the dysfunction and disability.”

The main question concerns when to operate on orthopedic injuries in a patient with traumatic brain injury, explained Dr. Rubel. Early fracture fixation in blunt trauma patients is generally recommended, but many doctors are hesitant to perform early fixation in patients with severe brain trauma. There is a widespread view that fracture fixation should be postponed to protect the injured brain.

This view was challenged by a study examining the timing of fracture fixation in blunt trauma patients with severe head injuries (Am. J. Surg. 1998;176:324–9). Investigators reviewed records of 47 consecutive blunt trauma patients with both severe head injuries and long bone fractures requiring surgical fixation. Twenty-two patients had undergone early fracture fixation within 24 hours of hospital admission (mean time 17 hours), and 25 patients had undergone delayed treatment (mean time 143 hours). Review of patient records revealed that there were no significant differences between the two groups in terms of neurologic or orthopedic complications, length of hospital stay, or mortality. Thus, delay of fracture fixation did not protect the injured brain in this study population.

Dr. Rubel described a young patient who was treated at FLENI Institute for a severe traumatic head injury and multiple fractures. The head injury required decompression with a wide craniotomy. The patient remained in a coma for 6 weeks, and CT scans showed cerebral edema. Radiography revealed a huge intrapelvic calcification affecting the bladder and rectum, malunion of the pelvis, malunion of the tibia, and a radio-ulnar synostosis. She was placed in long arm and leg casts and was told that she could not have pelvic surgery because of the likelihood that she would die during the procedure.

“Once at our institution, the malunion of the tibia was corrected upon admission, and she was allowed to exercise on a rehabilitation bicycle,” said Dr. Rubel. The second step was resection of the forearm synostosis, which improved the position of the hand for daily activities and allowed her to rehabilitate her writing capabilities, he said. As the brain edema resolved, the patient gradually improved both in cognition and in function. Restoration of the pelvic malunion with serial osteotomies was the last surgical intervention.

“It's hard for patients to understand not to put weight on the leg, since the brain is still inflamed,” said Dr. Rubel. Rehabilitation was performed in a pool with chest-deep water. At 6 months from the accident, she returned to her normal activities.

Immediately after trauma, there is a window of opportunity when treatment of orthopedic injuries is optimal. Use that window of opportunity around trauma and start helping the patients right away to minimize their skeletal and psychological and cognitive dysfunction, advised Dr. Rubel.

BUENOS AIRES — Treatment of orthopedic injuries in patients with traumatic brain injury should not be delayed, Dr. Ivan Rubel said at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

A population-based study conducted in the Twin Cities area of Minnesota found that most patients who were seen in an emergency department for traumatic brain injury had received the injury from sports and recreational activities (Minn. Med. 2006;89:40–4). The traumatic brain injuries that trauma surgeons are more likely to encounter, however, come from falls or car accidents, said Dr. Rubel, director of the orthopedics and traumatology department at FLENI Institute in Buenos Aires.

Pelvic and extremity fractures are common in patients with traumatic brain injury. Many skeletal injuries are not given priority, or might even be missed. However, as the survival rate of patients with traumatic brain injury has increased, there is a greater emphasis on minimizing dysfunction and disability in these patients, particularly when the dysfunction and disability arise from concomitant orthopedic trauma.

In a study of health-related quality of life in pediatric patients during the first year following a traumatic brain injury, the treatment of associated injuries was shown to have a greater impact than other factors such as patient or family characteristics (Arch. Pediatr. Adolesc. Med. 2006;160:252–60). “With the recent advances in intensive care medicine, most of these patients survive,” said Dr. Rubel. “We have to focus on minimizing the dysfunction and disability.”

The main question concerns when to operate on orthopedic injuries in a patient with traumatic brain injury, explained Dr. Rubel. Early fracture fixation in blunt trauma patients is generally recommended, but many doctors are hesitant to perform early fixation in patients with severe brain trauma. There is a widespread view that fracture fixation should be postponed to protect the injured brain.

This view was challenged by a study examining the timing of fracture fixation in blunt trauma patients with severe head injuries (Am. J. Surg. 1998;176:324–9). Investigators reviewed records of 47 consecutive blunt trauma patients with both severe head injuries and long bone fractures requiring surgical fixation. Twenty-two patients had undergone early fracture fixation within 24 hours of hospital admission (mean time 17 hours), and 25 patients had undergone delayed treatment (mean time 143 hours). Review of patient records revealed that there were no significant differences between the two groups in terms of neurologic or orthopedic complications, length of hospital stay, or mortality. Thus, delay of fracture fixation did not protect the injured brain in this study population.

Dr. Rubel described a young patient who was treated at FLENI Institute for a severe traumatic head injury and multiple fractures. The head injury required decompression with a wide craniotomy. The patient remained in a coma for 6 weeks, and CT scans showed cerebral edema. Radiography revealed a huge intrapelvic calcification affecting the bladder and rectum, malunion of the pelvis, malunion of the tibia, and a radio-ulnar synostosis. She was placed in long arm and leg casts and was told that she could not have pelvic surgery because of the likelihood that she would die during the procedure.

“Once at our institution, the malunion of the tibia was corrected upon admission, and she was allowed to exercise on a rehabilitation bicycle,” said Dr. Rubel. The second step was resection of the forearm synostosis, which improved the position of the hand for daily activities and allowed her to rehabilitate her writing capabilities, he said. As the brain edema resolved, the patient gradually improved both in cognition and in function. Restoration of the pelvic malunion with serial osteotomies was the last surgical intervention.

“It's hard for patients to understand not to put weight on the leg, since the brain is still inflamed,” said Dr. Rubel. Rehabilitation was performed in a pool with chest-deep water. At 6 months from the accident, she returned to her normal activities.

Immediately after trauma, there is a window of opportunity when treatment of orthopedic injuries is optimal. Use that window of opportunity around trauma and start helping the patients right away to minimize their skeletal and psychological and cognitive dysfunction, advised Dr. Rubel.

BUENOS AIRES — Treatment of orthopedic injuries in patients with traumatic brain injury should not be delayed, Dr. Ivan Rubel said at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

A population-based study conducted in the Twin Cities area of Minnesota found that most patients who were seen in an emergency department for traumatic brain injury had received the injury from sports and recreational activities (Minn. Med. 2006;89:40–4). The traumatic brain injuries that trauma surgeons are more likely to encounter, however, come from falls or car accidents, said Dr. Rubel, director of the orthopedics and traumatology department at FLENI Institute in Buenos Aires.

Pelvic and extremity fractures are common in patients with traumatic brain injury. Many skeletal injuries are not given priority, or might even be missed. However, as the survival rate of patients with traumatic brain injury has increased, there is a greater emphasis on minimizing dysfunction and disability in these patients, particularly when the dysfunction and disability arise from concomitant orthopedic trauma.

In a study of health-related quality of life in pediatric patients during the first year following a traumatic brain injury, the treatment of associated injuries was shown to have a greater impact than other factors such as patient or family characteristics (Arch. Pediatr. Adolesc. Med. 2006;160:252–60). “With the recent advances in intensive care medicine, most of these patients survive,” said Dr. Rubel. “We have to focus on minimizing the dysfunction and disability.”

The main question concerns when to operate on orthopedic injuries in a patient with traumatic brain injury, explained Dr. Rubel. Early fracture fixation in blunt trauma patients is generally recommended, but many doctors are hesitant to perform early fixation in patients with severe brain trauma. There is a widespread view that fracture fixation should be postponed to protect the injured brain.

This view was challenged by a study examining the timing of fracture fixation in blunt trauma patients with severe head injuries (Am. J. Surg. 1998;176:324–9). Investigators reviewed records of 47 consecutive blunt trauma patients with both severe head injuries and long bone fractures requiring surgical fixation. Twenty-two patients had undergone early fracture fixation within 24 hours of hospital admission (mean time 17 hours), and 25 patients had undergone delayed treatment (mean time 143 hours). Review of patient records revealed that there were no significant differences between the two groups in terms of neurologic or orthopedic complications, length of hospital stay, or mortality. Thus, delay of fracture fixation did not protect the injured brain in this study population.

Dr. Rubel described a young patient who was treated at FLENI Institute for a severe traumatic head injury and multiple fractures. The head injury required decompression with a wide craniotomy. The patient remained in a coma for 6 weeks, and CT scans showed cerebral edema. Radiography revealed a huge intrapelvic calcification affecting the bladder and rectum, malunion of the pelvis, malunion of the tibia, and a radio-ulnar synostosis. She was placed in long arm and leg casts and was told that she could not have pelvic surgery because of the likelihood that she would die during the procedure.

“Once at our institution, the malunion of the tibia was corrected upon admission, and she was allowed to exercise on a rehabilitation bicycle,” said Dr. Rubel. The second step was resection of the forearm synostosis, which improved the position of the hand for daily activities and allowed her to rehabilitate her writing capabilities, he said. As the brain edema resolved, the patient gradually improved both in cognition and in function. Restoration of the pelvic malunion with serial osteotomies was the last surgical intervention.

“It's hard for patients to understand not to put weight on the leg, since the brain is still inflamed,” said Dr. Rubel. Rehabilitation was performed in a pool with chest-deep water. At 6 months from the accident, she returned to her normal activities.

Immediately after trauma, there is a window of opportunity when treatment of orthopedic injuries is optimal. Use that window of opportunity around trauma and start helping the patients right away to minimize their skeletal and psychological and cognitive dysfunction, advised Dr. Rubel.

BUENOS AIRES — Glucocorticoid steroids are widely used to treat acute spinal cord injuries, but there is no clear consensus on their use, reported Dr. Keith D.K. Luk at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

The initial spinal cord injury triggers a complex cascade of molecular and cellular events. Lipid peroxidation of cellular membranes occurs as a secondary effect of spinal cord injuries and results in irreversible damage, said Dr. Luk, chair professor and head of the department of orthopedics and traumatology at the University of Hong Kong.

The National Acute Spinal Cord Injury Study (NASCIS) group conducted the first randomized, multicenter clinical study to examine the efficacy of methylprednisolone for acute spinal cord injury. The prevailing assumption of the benefits of methylprednisolone precluded the inclusion of a placebo group in the study design, as it was considered unethical to deny patients a treatment considered to be the standard of care. Thus, all patients in NASCIS I received methylprednisolone.

NASCIS I, initiated in 1979, compared functional outcome in 330 patients randomized to receive a 10-day regimen of methylprednisolone by intravenous bolus of either a low dosage of 100 mg per day or a high dosage of 1,000 mg per day (JAMA 1984;251:45–52). Outcome was assessed at 6 months and 12 months. Unexpectedly, the results showed no significant differences in neurologic benefit. The higher dose of methylprednisolone was associated with increased risk of infection, with no apparent increase in neurologic benefit.

A second clinical study (NASCIS II) was undertaken in which 162 patients were given a higher dose of methylprednisolone over a shorter period of time, and 171 patients received a placebo (N. Engl. J. Med. 1990;322:1405–11). The methylprednisolone regimen consisted of an intravenous bolus of 30 mg/kg, followed by a 23-hour infusion of methylprednisolone at 5.4 mg/kg per hour. A third treatment group of 154 patients received 24-hour dosing with naloxone, an opiate receptor antagonist.

High-dose methylprednisolone treatment initiated within 8 hours showed significant neurologic benefit, and the functional benefits were sustained at 6 weeks, 6 months, and 1 year. Treatment had to be given within an 8-hour window after the initial injury, before the onset of lipid peroxidation.

Conclusions of NASCIS II were controversial. The study analyses were criticized, particularly regarding the issue of post hoc stratification based on time of treatment (J. Neurosurg. 2000;93[Suppl 1]:1–7).

A third randomized, controlled clinical trial, known as NASCIS III, compared three treatments in 499 patients with acute spinal cord injury (JAMA 1997;277:1597–604). The methylprednisolone regimen in NASCIS II served as the active control. All patients were treated within 8 hours of the initial injury. Before randomization, all patients received an initial intravenous bolus of high-dose methylprednisolone (30 mg/kg). Patients in the methylprednisolone treatment groups then were given methylprednisolone infusion at 5.4 mg/kg per hour for 24 hours (active control group) or for 48 hours. The third treatment group received infusions of tirilazad mesylate over a 48-hour period.

The results showed that all treatment regimens were comparable in patients treated within 3 hours of injury. Those treated within 3 hours who received methylprednisolone for 48 hours had significantly better neurologic recovery, although the 48-hour treatment group experienced more side effects associated with steroid use. Controversy over data analysis in NASCIS II and NASCIS III remains.

A summary statement from the Spine Focus Panel suggested indications for methylprednisolone use in acute nonpenetrating spinal cord injury (Spine 2001;26[Suppl 24]:55). Treatment initiated within 3 hours should follow the methylprednisolone regimen used in NASCIS II (24 hours), and treatment initiated after 3 hours but before 8 hours should follow the high-dose regimen used in NASCIS III (48 hours). Methylprednisolone treatment should not be started after 8 hours, nor is it recommended in acute penetrating spinal cord injury, according to the Spine Focus Panel statement.

The Canadian Association of Emergency Physicians issued a position statement in 2003 declaring that “methylprednisolone for acute spinal cord injury is not a standard of care; it is only a treatment option.”

BUENOS AIRES — Glucocorticoid steroids are widely used to treat acute spinal cord injuries, but there is no clear consensus on their use, reported Dr. Keith D.K. Luk at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

The initial spinal cord injury triggers a complex cascade of molecular and cellular events. Lipid peroxidation of cellular membranes occurs as a secondary effect of spinal cord injuries and results in irreversible damage, said Dr. Luk, chair professor and head of the department of orthopedics and traumatology at the University of Hong Kong.

The National Acute Spinal Cord Injury Study (NASCIS) group conducted the first randomized, multicenter clinical study to examine the efficacy of methylprednisolone for acute spinal cord injury. The prevailing assumption of the benefits of methylprednisolone precluded the inclusion of a placebo group in the study design, as it was considered unethical to deny patients a treatment considered to be the standard of care. Thus, all patients in NASCIS I received methylprednisolone.

NASCIS I, initiated in 1979, compared functional outcome in 330 patients randomized to receive a 10-day regimen of methylprednisolone by intravenous bolus of either a low dosage of 100 mg per day or a high dosage of 1,000 mg per day (JAMA 1984;251:45–52). Outcome was assessed at 6 months and 12 months. Unexpectedly, the results showed no significant differences in neurologic benefit. The higher dose of methylprednisolone was associated with increased risk of infection, with no apparent increase in neurologic benefit.

A second clinical study (NASCIS II) was undertaken in which 162 patients were given a higher dose of methylprednisolone over a shorter period of time, and 171 patients received a placebo (N. Engl. J. Med. 1990;322:1405–11). The methylprednisolone regimen consisted of an intravenous bolus of 30 mg/kg, followed by a 23-hour infusion of methylprednisolone at 5.4 mg/kg per hour. A third treatment group of 154 patients received 24-hour dosing with naloxone, an opiate receptor antagonist.

High-dose methylprednisolone treatment initiated within 8 hours showed significant neurologic benefit, and the functional benefits were sustained at 6 weeks, 6 months, and 1 year. Treatment had to be given within an 8-hour window after the initial injury, before the onset of lipid peroxidation.

Conclusions of NASCIS II were controversial. The study analyses were criticized, particularly regarding the issue of post hoc stratification based on time of treatment (J. Neurosurg. 2000;93[Suppl 1]:1–7).

A third randomized, controlled clinical trial, known as NASCIS III, compared three treatments in 499 patients with acute spinal cord injury (JAMA 1997;277:1597–604). The methylprednisolone regimen in NASCIS II served as the active control. All patients were treated within 8 hours of the initial injury. Before randomization, all patients received an initial intravenous bolus of high-dose methylprednisolone (30 mg/kg). Patients in the methylprednisolone treatment groups then were given methylprednisolone infusion at 5.4 mg/kg per hour for 24 hours (active control group) or for 48 hours. The third treatment group received infusions of tirilazad mesylate over a 48-hour period.

The results showed that all treatment regimens were comparable in patients treated within 3 hours of injury. Those treated within 3 hours who received methylprednisolone for 48 hours had significantly better neurologic recovery, although the 48-hour treatment group experienced more side effects associated with steroid use. Controversy over data analysis in NASCIS II and NASCIS III remains.

A summary statement from the Spine Focus Panel suggested indications for methylprednisolone use in acute nonpenetrating spinal cord injury (Spine 2001;26[Suppl 24]:55). Treatment initiated within 3 hours should follow the methylprednisolone regimen used in NASCIS II (24 hours), and treatment initiated after 3 hours but before 8 hours should follow the high-dose regimen used in NASCIS III (48 hours). Methylprednisolone treatment should not be started after 8 hours, nor is it recommended in acute penetrating spinal cord injury, according to the Spine Focus Panel statement.

The Canadian Association of Emergency Physicians issued a position statement in 2003 declaring that “methylprednisolone for acute spinal cord injury is not a standard of care; it is only a treatment option.”

BUENOS AIRES — Glucocorticoid steroids are widely used to treat acute spinal cord injuries, but there is no clear consensus on their use, reported Dr. Keith D.K. Luk at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

The initial spinal cord injury triggers a complex cascade of molecular and cellular events. Lipid peroxidation of cellular membranes occurs as a secondary effect of spinal cord injuries and results in irreversible damage, said Dr. Luk, chair professor and head of the department of orthopedics and traumatology at the University of Hong Kong.

The National Acute Spinal Cord Injury Study (NASCIS) group conducted the first randomized, multicenter clinical study to examine the efficacy of methylprednisolone for acute spinal cord injury. The prevailing assumption of the benefits of methylprednisolone precluded the inclusion of a placebo group in the study design, as it was considered unethical to deny patients a treatment considered to be the standard of care. Thus, all patients in NASCIS I received methylprednisolone.

NASCIS I, initiated in 1979, compared functional outcome in 330 patients randomized to receive a 10-day regimen of methylprednisolone by intravenous bolus of either a low dosage of 100 mg per day or a high dosage of 1,000 mg per day (JAMA 1984;251:45–52). Outcome was assessed at 6 months and 12 months. Unexpectedly, the results showed no significant differences in neurologic benefit. The higher dose of methylprednisolone was associated with increased risk of infection, with no apparent increase in neurologic benefit.

A second clinical study (NASCIS II) was undertaken in which 162 patients were given a higher dose of methylprednisolone over a shorter period of time, and 171 patients received a placebo (N. Engl. J. Med. 1990;322:1405–11). The methylprednisolone regimen consisted of an intravenous bolus of 30 mg/kg, followed by a 23-hour infusion of methylprednisolone at 5.4 mg/kg per hour. A third treatment group of 154 patients received 24-hour dosing with naloxone, an opiate receptor antagonist.

High-dose methylprednisolone treatment initiated within 8 hours showed significant neurologic benefit, and the functional benefits were sustained at 6 weeks, 6 months, and 1 year. Treatment had to be given within an 8-hour window after the initial injury, before the onset of lipid peroxidation.

Conclusions of NASCIS II were controversial. The study analyses were criticized, particularly regarding the issue of post hoc stratification based on time of treatment (J. Neurosurg. 2000;93[Suppl 1]:1–7).

A third randomized, controlled clinical trial, known as NASCIS III, compared three treatments in 499 patients with acute spinal cord injury (JAMA 1997;277:1597–604). The methylprednisolone regimen in NASCIS II served as the active control. All patients were treated within 8 hours of the initial injury. Before randomization, all patients received an initial intravenous bolus of high-dose methylprednisolone (30 mg/kg). Patients in the methylprednisolone treatment groups then were given methylprednisolone infusion at 5.4 mg/kg per hour for 24 hours (active control group) or for 48 hours. The third treatment group received infusions of tirilazad mesylate over a 48-hour period.

The results showed that all treatment regimens were comparable in patients treated within 3 hours of injury. Those treated within 3 hours who received methylprednisolone for 48 hours had significantly better neurologic recovery, although the 48-hour treatment group experienced more side effects associated with steroid use. Controversy over data analysis in NASCIS II and NASCIS III remains.

A summary statement from the Spine Focus Panel suggested indications for methylprednisolone use in acute nonpenetrating spinal cord injury (Spine 2001;26[Suppl 24]:55). Treatment initiated within 3 hours should follow the methylprednisolone regimen used in NASCIS II (24 hours), and treatment initiated after 3 hours but before 8 hours should follow the high-dose regimen used in NASCIS III (48 hours). Methylprednisolone treatment should not be started after 8 hours, nor is it recommended in acute penetrating spinal cord injury, according to the Spine Focus Panel statement.

The Canadian Association of Emergency Physicians issued a position statement in 2003 declaring that “methylprednisolone for acute spinal cord injury is not a standard of care; it is only a treatment option.”

A healthy 4-year-old boy sustained a closed fracture of the arm and died of Clostridium sordellii infection 4 days later. Death occurred despite intravenous antibiotic therapy and aggressive surgical debridement of necrotic tissue.

Dr. Michael Aldape and his colleagues at the Veterans Affairs Medical Center in Boise, Idaho, describe this case and summarize clinical features of 44 additional cases of C. sordellii infection reported in the literature (Clin. Infect. Dis. 2006;43:1436–46). Almost all of the affected individuals had been healthy before infection.

About 24 hours after the 4-year-old was discharged from the emergency department in a long arm cast for a closed transverse fracture of the arm, severe pain and swelling of the arm and fingers led to his hospital admission. He was taken to the operating room after intravenous cefazolin was started. Volar fasciotomy of the superficial and deep compartments of the arm was required. Although he was afebrile, with a blood pressure of 128/82 mm Hg, his pulse increased to 150 beats/min.

Twelve hours later, the boy's pulse increased to 164 beats/min, and his blood pressure dropped to 108/60 mm Hg. He remained afebrile. The left forearm became grossly swollen, so intravenous vancomycin was started. Gentamicin and piperacillin were started when WBC and platelet counts increased. A second surgery revealed necrotic and foul-smelling muscle, fat, and fascia, with complete stoppage of blood flow to the wrist, Dr. Aldape and his colleagues said. Tissue samples obtained at both surgeries subsequently revealed large, gram-negative rods identified as C. sordellii.

The boy's WBC count continued to climb the next day, and by midafternoon he was hemodynamically unstable, with increasing hypotension, tachycardia, metabolic acidosis, and decreased urine output. Hours later, ultrasound-guided pericardiocentesis produced straw-colored liquid. Refractory hypotension developed, and the patient died.

Two other cases involved C. sordellii infections in children. One was a 17-day-old infant who developed neonatal toxic omphalitis and died despite aggressive treatment that included multiple debridements and broad-spectrum antibiotics. The third case was a 12-year-old boy who developed C. sordellii sepsis following an ear infection but survived after an intensive 2-week course of antibiotic therapy and supportive care, the authors said.

Of the 45 cases of C. sordellii infection, 19 occurred following trauma or nongynecologic surgery, with 53% mortality. Ten cases of C. sordellii infection in injection drug users were reported, with 50% mortality. Eight cases were associated with normal childbirth, five with medically induced abortion, and two with spontaneous abortion. All 15 of the latter cases were fatal. One case of fatal spontaneous endometritis was reported.

Diagnosis of C. sordellii infection is challenging because initial symptoms are nonspecific. Although patients may have deep infection, they are afebrile and lack signs of local infection. “By the time local signs and symptoms appear, patients are hypotensive and organ failure is occurring,” the researchers said. A collection of six distinctive clinical features uniquely characterizes C. sordellii infection: marked leukocytosis, refractory hypotension, severe tachycardia, profound capillary leak syndrome, hemoconcentration, and persistent absence of fever, they added.

Little information is available concerning appropriate antimicrobial treatment of C. sordellii infection. C. sordellii is likely to be resistant to aminoglycosides and sulfonamides but susceptible to beta-lactams, chloramphenicol, and tetracycline. There is no commercially available preparation of C. sordellii antitoxin, they said.

“Physicians should suspect C. sordellii infection in patients who present within 2–7 days after an injury, surgical procedure, drug injection, childbirth, or MIA [medically induced abortion] and… complain of pain, nausea, vomiting, and diarrhea but are afebrile,” the researchers concluded.

A healthy 4-year-old boy sustained a closed fracture of the arm and died of Clostridium sordellii infection 4 days later. Death occurred despite intravenous antibiotic therapy and aggressive surgical debridement of necrotic tissue.

Dr. Michael Aldape and his colleagues at the Veterans Affairs Medical Center in Boise, Idaho, describe this case and summarize clinical features of 44 additional cases of C. sordellii infection reported in the literature (Clin. Infect. Dis. 2006;43:1436–46). Almost all of the affected individuals had been healthy before infection.

About 24 hours after the 4-year-old was discharged from the emergency department in a long arm cast for a closed transverse fracture of the arm, severe pain and swelling of the arm and fingers led to his hospital admission. He was taken to the operating room after intravenous cefazolin was started. Volar fasciotomy of the superficial and deep compartments of the arm was required. Although he was afebrile, with a blood pressure of 128/82 mm Hg, his pulse increased to 150 beats/min.

Twelve hours later, the boy's pulse increased to 164 beats/min, and his blood pressure dropped to 108/60 mm Hg. He remained afebrile. The left forearm became grossly swollen, so intravenous vancomycin was started. Gentamicin and piperacillin were started when WBC and platelet counts increased. A second surgery revealed necrotic and foul-smelling muscle, fat, and fascia, with complete stoppage of blood flow to the wrist, Dr. Aldape and his colleagues said. Tissue samples obtained at both surgeries subsequently revealed large, gram-negative rods identified as C. sordellii.

The boy's WBC count continued to climb the next day, and by midafternoon he was hemodynamically unstable, with increasing hypotension, tachycardia, metabolic acidosis, and decreased urine output. Hours later, ultrasound-guided pericardiocentesis produced straw-colored liquid. Refractory hypotension developed, and the patient died.

Two other cases involved C. sordellii infections in children. One was a 17-day-old infant who developed neonatal toxic omphalitis and died despite aggressive treatment that included multiple debridements and broad-spectrum antibiotics. The third case was a 12-year-old boy who developed C. sordellii sepsis following an ear infection but survived after an intensive 2-week course of antibiotic therapy and supportive care, the authors said.

Of the 45 cases of C. sordellii infection, 19 occurred following trauma or nongynecologic surgery, with 53% mortality. Ten cases of C. sordellii infection in injection drug users were reported, with 50% mortality. Eight cases were associated with normal childbirth, five with medically induced abortion, and two with spontaneous abortion. All 15 of the latter cases were fatal. One case of fatal spontaneous endometritis was reported.

Diagnosis of C. sordellii infection is challenging because initial symptoms are nonspecific. Although patients may have deep infection, they are afebrile and lack signs of local infection. “By the time local signs and symptoms appear, patients are hypotensive and organ failure is occurring,” the researchers said. A collection of six distinctive clinical features uniquely characterizes C. sordellii infection: marked leukocytosis, refractory hypotension, severe tachycardia, profound capillary leak syndrome, hemoconcentration, and persistent absence of fever, they added.

Little information is available concerning appropriate antimicrobial treatment of C. sordellii infection. C. sordellii is likely to be resistant to aminoglycosides and sulfonamides but susceptible to beta-lactams, chloramphenicol, and tetracycline. There is no commercially available preparation of C. sordellii antitoxin, they said.

“Physicians should suspect C. sordellii infection in patients who present within 2–7 days after an injury, surgical procedure, drug injection, childbirth, or MIA [medically induced abortion] and… complain of pain, nausea, vomiting, and diarrhea but are afebrile,” the researchers concluded.

A healthy 4-year-old boy sustained a closed fracture of the arm and died of Clostridium sordellii infection 4 days later. Death occurred despite intravenous antibiotic therapy and aggressive surgical debridement of necrotic tissue.

Dr. Michael Aldape and his colleagues at the Veterans Affairs Medical Center in Boise, Idaho, describe this case and summarize clinical features of 44 additional cases of C. sordellii infection reported in the literature (Clin. Infect. Dis. 2006;43:1436–46). Almost all of the affected individuals had been healthy before infection.

About 24 hours after the 4-year-old was discharged from the emergency department in a long arm cast for a closed transverse fracture of the arm, severe pain and swelling of the arm and fingers led to his hospital admission. He was taken to the operating room after intravenous cefazolin was started. Volar fasciotomy of the superficial and deep compartments of the arm was required. Although he was afebrile, with a blood pressure of 128/82 mm Hg, his pulse increased to 150 beats/min.

Twelve hours later, the boy's pulse increased to 164 beats/min, and his blood pressure dropped to 108/60 mm Hg. He remained afebrile. The left forearm became grossly swollen, so intravenous vancomycin was started. Gentamicin and piperacillin were started when WBC and platelet counts increased. A second surgery revealed necrotic and foul-smelling muscle, fat, and fascia, with complete stoppage of blood flow to the wrist, Dr. Aldape and his colleagues said. Tissue samples obtained at both surgeries subsequently revealed large, gram-negative rods identified as C. sordellii.

The boy's WBC count continued to climb the next day, and by midafternoon he was hemodynamically unstable, with increasing hypotension, tachycardia, metabolic acidosis, and decreased urine output. Hours later, ultrasound-guided pericardiocentesis produced straw-colored liquid. Refractory hypotension developed, and the patient died.

Two other cases involved C. sordellii infections in children. One was a 17-day-old infant who developed neonatal toxic omphalitis and died despite aggressive treatment that included multiple debridements and broad-spectrum antibiotics. The third case was a 12-year-old boy who developed C. sordellii sepsis following an ear infection but survived after an intensive 2-week course of antibiotic therapy and supportive care, the authors said.

Of the 45 cases of C. sordellii infection, 19 occurred following trauma or nongynecologic surgery, with 53% mortality. Ten cases of C. sordellii infection in injection drug users were reported, with 50% mortality. Eight cases were associated with normal childbirth, five with medically induced abortion, and two with spontaneous abortion. All 15 of the latter cases were fatal. One case of fatal spontaneous endometritis was reported.

Diagnosis of C. sordellii infection is challenging because initial symptoms are nonspecific. Although patients may have deep infection, they are afebrile and lack signs of local infection. “By the time local signs and symptoms appear, patients are hypotensive and organ failure is occurring,” the researchers said. A collection of six distinctive clinical features uniquely characterizes C. sordellii infection: marked leukocytosis, refractory hypotension, severe tachycardia, profound capillary leak syndrome, hemoconcentration, and persistent absence of fever, they added.

Little information is available concerning appropriate antimicrobial treatment of C. sordellii infection. C. sordellii is likely to be resistant to aminoglycosides and sulfonamides but susceptible to beta-lactams, chloramphenicol, and tetracycline. There is no commercially available preparation of C. sordellii antitoxin, they said.

“Physicians should suspect C. sordellii infection in patients who present within 2–7 days after an injury, surgical procedure, drug injection, childbirth, or MIA [medically induced abortion] and… complain of pain, nausea, vomiting, and diarrhea but are afebrile,” the researchers concluded.

MENDOZA, ARGENTINA – Many studies show that light to moderate drinkers have better cognitive function than do abstainers–particularly in old age–Dr. Roger Pinder reported at the Sixth World Congress on Depressive Disorders.

In addition, moderate daily consumption of wine appears to reduce the risk for dementia and improve cognitive function, with a greater beneficial effect for women than for men.

The association between alcohol consumption and cognitive function often is illustrated as a J-shaped curve, because heavy alcohol consumption, or binge drinking, is associated with worse cognitive functioning and increased risk of dementia, said Dr. Pinder, an independent consultant in Dublin.

The association between alcohol consumption and risk of dementia has been investigated in several large cohort studies and in case-control studies analyzing a subset of subjects from within a larger community-based cohort.

A 3-year study of elderly subjects (older than 65 years) in the Bordeaux area of France and a similar 6-year study of subjects older than 55 years in Rotterdam, the Netherlands, showed beneficial effects of moderate alcohol consumption in lowering the risk of dementia.

A case-control study from a U.S. community-based cohort of older subjects compared more than 300 pairs of subjects with incident dementia to controls and found significantly lower risk for dementia associated with light to moderate alcohol consumption.

The Bordeaux study focused on wine consumption. In the U.S. study, wine consumption had a greater benefit than did consumption of beer or spirits. The Rotterdam study showed no significant differences based on type of alcohol consumed.

Three major population-based studies with long-term follow-up have demonstrated an association between moderate alcohol consumption and improved cognition: The Whitehall Study of British Civil Servants, the U.S. Nurse's Health Study, and the Women's Health Initiative Memory Study.

The Whitehall Study, conducted in the United Kingdom, was a cohort study of 4,272 male and 1,761 female civil servants, with a median follow-up of 11 years. Assessment of cognitive function was performed when the subjects were aged 46–68 years. Cognitive function was significantly better in drinkers, compared with nondrinkers, even in those who drank more than 240 g alcohol per week (Am. J. Epidemiol. 2004;160:240–7). The benefit was greater in women than in men.

In the long-term, U.S.-based Nurse's Health Study, cognitive function was evaluated in 12,480 female nurses, aged 70–81 years. Subjects were reevaluated after 2 years. Compared with nondrinkers, moderate drinkers had higher mean cognitive scores and showed reduced risks of cognitive decline (N. Engl. J. Med. 2005;352:245–53).

The Women's Health Initiative Memory Study examined cognitive function and alcohol consumption in more than 4,000 women aged 65–79 years, with an average follow-up of 4 years. Relative to no alcohol consumption, moderate consumption of alcohol was associated with better cognition and reduced risk of cognitive decline (Am. J. Epidemiol. 2005;161:228–38).

One caveat when it comes to assessing the beneficial effects of wine is the presence of potential confounding factors in the studies. Alcohol consumption in many studies is not limited to wine but also includes beer or spirits. Compared with those who drink beer or spirits, wine drinkers tend to have healthier lifestyles. In addition, wine drinkers are more likely to be women, college graduates, and nonsmokers, Dr. Pinder said.

Finally, heavy drinkers often underestimate–or lie about–their alcohol consumption, which can distort results by lowering the apparent threshold for harmful effects. Nonetheless, in several studies, wine consumption appeared to be better than consumption of beer or spirits at improving cognitive function.

Consumption of red wine seems to have a stronger beneficial effect than consumption of white wine or rosé, Dr. Pinder reported. The beneficial effects of red wine may largely be attributable to antioxidants derived from grape skins. “Unlike beer and distilled spirits, wine contains not only alcohol, but also has a lot of polyphenolic antioxidant compounds extracted when the grapes are vinified,” Dr. Pinder said. “Red wine contains more polyphenols than white or rosé, simply because of the greater extraction from the grape skins. And they use grape varieties that are rich in polyphenols.”

MENDOZA, ARGENTINA – Many studies show that light to moderate drinkers have better cognitive function than do abstainers–particularly in old age–Dr. Roger Pinder reported at the Sixth World Congress on Depressive Disorders.

In addition, moderate daily consumption of wine appears to reduce the risk for dementia and improve cognitive function, with a greater beneficial effect for women than for men.

The association between alcohol consumption and cognitive function often is illustrated as a J-shaped curve, because heavy alcohol consumption, or binge drinking, is associated with worse cognitive functioning and increased risk of dementia, said Dr. Pinder, an independent consultant in Dublin.

The association between alcohol consumption and risk of dementia has been investigated in several large cohort studies and in case-control studies analyzing a subset of subjects from within a larger community-based cohort.

A 3-year study of elderly subjects (older than 65 years) in the Bordeaux area of France and a similar 6-year study of subjects older than 55 years in Rotterdam, the Netherlands, showed beneficial effects of moderate alcohol consumption in lowering the risk of dementia.

A case-control study from a U.S. community-based cohort of older subjects compared more than 300 pairs of subjects with incident dementia to controls and found significantly lower risk for dementia associated with light to moderate alcohol consumption.

The Bordeaux study focused on wine consumption. In the U.S. study, wine consumption had a greater benefit than did consumption of beer or spirits. The Rotterdam study showed no significant differences based on type of alcohol consumed.

Three major population-based studies with long-term follow-up have demonstrated an association between moderate alcohol consumption and improved cognition: The Whitehall Study of British Civil Servants, the U.S. Nurse's Health Study, and the Women's Health Initiative Memory Study.

The Whitehall Study, conducted in the United Kingdom, was a cohort study of 4,272 male and 1,761 female civil servants, with a median follow-up of 11 years. Assessment of cognitive function was performed when the subjects were aged 46–68 years. Cognitive function was significantly better in drinkers, compared with nondrinkers, even in those who drank more than 240 g alcohol per week (Am. J. Epidemiol. 2004;160:240–7). The benefit was greater in women than in men.

In the long-term, U.S.-based Nurse's Health Study, cognitive function was evaluated in 12,480 female nurses, aged 70–81 years. Subjects were reevaluated after 2 years. Compared with nondrinkers, moderate drinkers had higher mean cognitive scores and showed reduced risks of cognitive decline (N. Engl. J. Med. 2005;352:245–53).

The Women's Health Initiative Memory Study examined cognitive function and alcohol consumption in more than 4,000 women aged 65–79 years, with an average follow-up of 4 years. Relative to no alcohol consumption, moderate consumption of alcohol was associated with better cognition and reduced risk of cognitive decline (Am. J. Epidemiol. 2005;161:228–38).

One caveat when it comes to assessing the beneficial effects of wine is the presence of potential confounding factors in the studies. Alcohol consumption in many studies is not limited to wine but also includes beer or spirits. Compared with those who drink beer or spirits, wine drinkers tend to have healthier lifestyles. In addition, wine drinkers are more likely to be women, college graduates, and nonsmokers, Dr. Pinder said.

Finally, heavy drinkers often underestimate–or lie about–their alcohol consumption, which can distort results by lowering the apparent threshold for harmful effects. Nonetheless, in several studies, wine consumption appeared to be better than consumption of beer or spirits at improving cognitive function.

Consumption of red wine seems to have a stronger beneficial effect than consumption of white wine or rosé, Dr. Pinder reported. The beneficial effects of red wine may largely be attributable to antioxidants derived from grape skins. “Unlike beer and distilled spirits, wine contains not only alcohol, but also has a lot of polyphenolic antioxidant compounds extracted when the grapes are vinified,” Dr. Pinder said. “Red wine contains more polyphenols than white or rosé, simply because of the greater extraction from the grape skins. And they use grape varieties that are rich in polyphenols.”

MENDOZA, ARGENTINA – Many studies show that light to moderate drinkers have better cognitive function than do abstainers–particularly in old age–Dr. Roger Pinder reported at the Sixth World Congress on Depressive Disorders.

In addition, moderate daily consumption of wine appears to reduce the risk for dementia and improve cognitive function, with a greater beneficial effect for women than for men.

The association between alcohol consumption and cognitive function often is illustrated as a J-shaped curve, because heavy alcohol consumption, or binge drinking, is associated with worse cognitive functioning and increased risk of dementia, said Dr. Pinder, an independent consultant in Dublin.

The association between alcohol consumption and risk of dementia has been investigated in several large cohort studies and in case-control studies analyzing a subset of subjects from within a larger community-based cohort.

A 3-year study of elderly subjects (older than 65 years) in the Bordeaux area of France and a similar 6-year study of subjects older than 55 years in Rotterdam, the Netherlands, showed beneficial effects of moderate alcohol consumption in lowering the risk of dementia.

A case-control study from a U.S. community-based cohort of older subjects compared more than 300 pairs of subjects with incident dementia to controls and found significantly lower risk for dementia associated with light to moderate alcohol consumption.

The Bordeaux study focused on wine consumption. In the U.S. study, wine consumption had a greater benefit than did consumption of beer or spirits. The Rotterdam study showed no significant differences based on type of alcohol consumed.

Three major population-based studies with long-term follow-up have demonstrated an association between moderate alcohol consumption and improved cognition: The Whitehall Study of British Civil Servants, the U.S. Nurse's Health Study, and the Women's Health Initiative Memory Study.

The Whitehall Study, conducted in the United Kingdom, was a cohort study of 4,272 male and 1,761 female civil servants, with a median follow-up of 11 years. Assessment of cognitive function was performed when the subjects were aged 46–68 years. Cognitive function was significantly better in drinkers, compared with nondrinkers, even in those who drank more than 240 g alcohol per week (Am. J. Epidemiol. 2004;160:240–7). The benefit was greater in women than in men.

In the long-term, U.S.-based Nurse's Health Study, cognitive function was evaluated in 12,480 female nurses, aged 70–81 years. Subjects were reevaluated after 2 years. Compared with nondrinkers, moderate drinkers had higher mean cognitive scores and showed reduced risks of cognitive decline (N. Engl. J. Med. 2005;352:245–53).

The Women's Health Initiative Memory Study examined cognitive function and alcohol consumption in more than 4,000 women aged 65–79 years, with an average follow-up of 4 years. Relative to no alcohol consumption, moderate consumption of alcohol was associated with better cognition and reduced risk of cognitive decline (Am. J. Epidemiol. 2005;161:228–38).

One caveat when it comes to assessing the beneficial effects of wine is the presence of potential confounding factors in the studies. Alcohol consumption in many studies is not limited to wine but also includes beer or spirits. Compared with those who drink beer or spirits, wine drinkers tend to have healthier lifestyles. In addition, wine drinkers are more likely to be women, college graduates, and nonsmokers, Dr. Pinder said.

Finally, heavy drinkers often underestimate–or lie about–their alcohol consumption, which can distort results by lowering the apparent threshold for harmful effects. Nonetheless, in several studies, wine consumption appeared to be better than consumption of beer or spirits at improving cognitive function.

Consumption of red wine seems to have a stronger beneficial effect than consumption of white wine or rosé, Dr. Pinder reported. The beneficial effects of red wine may largely be attributable to antioxidants derived from grape skins. “Unlike beer and distilled spirits, wine contains not only alcohol, but also has a lot of polyphenolic antioxidant compounds extracted when the grapes are vinified,” Dr. Pinder said. “Red wine contains more polyphenols than white or rosé, simply because of the greater extraction from the grape skins. And they use grape varieties that are rich in polyphenols.”

MENDOZA, ARGENTINA – All comorbid conditions increase the likelihood of substance abuse in adolescents with bipolar disorder, Dr. Harold I. Eist said at the Sixth World Congress on Depressive Disorders.

Many of the traits that characterize adolescence–such as impulsivity, rebelliousness, and curiosity–are intensified in bipolar teens. This is the case particularly in adolescents with comorbid attention-deficit hyperactivity disorder, said Dr. Eist, a psychiatrist in private practice in Bethesda, Md., and a past president of the American Psychiatric Association.

Furthermore, comorbidities such as conduct disorder or severe anxiety further exacerbate the condition, and some adolescents find it extremely difficult to resist the temptation of experimenting with substances.

Nearly 60% of the cases of bipolar disorder begin before the patient is 20 years old. Depending on the age of onset, adolescent bipolar disorder may look like childhood bipolar or adult bipolar disorder. Later-developing mania in adolescents is more likely to be euphoric, biphasic, and episodic, similar to adult mania.

Bipolar disorder in younger adolescents tends to be nonepisodic, chronic, and rapidly cycling, often ultradian and mixed. Early-onset bipolar disorder is characterized by severe irritability and affective storms, which are often violent. Euthymia is rare in early-onset bipolar disorder but common in the late-onset type.

In adolescents with early-onset bipolar disorder, 90% have ADHD, compared with 60% of adolescents who have later-occurring bipolar disorder.

Dr. Eist noted that adolescents with bipolar disorder who have had a significant manic episode will be less effective in school than they were before, and they won't know why. “These disorders are significant and should not be treated as if they were just aberrations of mood.”

The amount of time that an adolescent with bipolar disorder spends in mania or hypomania often is underestimated. Adolescents with bipolar disorder perceive hypomania and mild to moderate mania as normal, and recognize their condition only when they are in full mania. In addition, adolescents with bipolar disorder may experience euthymia as dull or boring.

It is important to keep in mind that adolescents are bad reporters, Dr. Eist said. “When they are depressed, they experience the depression as all consuming. They believe they have always been depressed and always will be depressed.” Adolescents with bipolar disorder are reluctant to keep mood charts, and if they do keep them, they are unlikely to be accurate. An independent assessment of the patient's mood is essential.

Protective factors in treating adolescents with bipolar disorder include positive support of an intact family, patient acceptance of psychotherapy and medication, patient cooperation with long-term therapy, high IQ, and little or no contact with the criminal justice system.

Substance abuse can be a “death sentence” for an adolescent with bipolar disorder, Dr. Eist said. Intervention is essential. “We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.”

'We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.' DR. EIST

MENDOZA, ARGENTINA – All comorbid conditions increase the likelihood of substance abuse in adolescents with bipolar disorder, Dr. Harold I. Eist said at the Sixth World Congress on Depressive Disorders.

Many of the traits that characterize adolescence–such as impulsivity, rebelliousness, and curiosity–are intensified in bipolar teens. This is the case particularly in adolescents with comorbid attention-deficit hyperactivity disorder, said Dr. Eist, a psychiatrist in private practice in Bethesda, Md., and a past president of the American Psychiatric Association.

Furthermore, comorbidities such as conduct disorder or severe anxiety further exacerbate the condition, and some adolescents find it extremely difficult to resist the temptation of experimenting with substances.

Nearly 60% of the cases of bipolar disorder begin before the patient is 20 years old. Depending on the age of onset, adolescent bipolar disorder may look like childhood bipolar or adult bipolar disorder. Later-developing mania in adolescents is more likely to be euphoric, biphasic, and episodic, similar to adult mania.

Bipolar disorder in younger adolescents tends to be nonepisodic, chronic, and rapidly cycling, often ultradian and mixed. Early-onset bipolar disorder is characterized by severe irritability and affective storms, which are often violent. Euthymia is rare in early-onset bipolar disorder but common in the late-onset type.

In adolescents with early-onset bipolar disorder, 90% have ADHD, compared with 60% of adolescents who have later-occurring bipolar disorder.

Dr. Eist noted that adolescents with bipolar disorder who have had a significant manic episode will be less effective in school than they were before, and they won't know why. “These disorders are significant and should not be treated as if they were just aberrations of mood.”

The amount of time that an adolescent with bipolar disorder spends in mania or hypomania often is underestimated. Adolescents with bipolar disorder perceive hypomania and mild to moderate mania as normal, and recognize their condition only when they are in full mania. In addition, adolescents with bipolar disorder may experience euthymia as dull or boring.

It is important to keep in mind that adolescents are bad reporters, Dr. Eist said. “When they are depressed, they experience the depression as all consuming. They believe they have always been depressed and always will be depressed.” Adolescents with bipolar disorder are reluctant to keep mood charts, and if they do keep them, they are unlikely to be accurate. An independent assessment of the patient's mood is essential.

Protective factors in treating adolescents with bipolar disorder include positive support of an intact family, patient acceptance of psychotherapy and medication, patient cooperation with long-term therapy, high IQ, and little or no contact with the criminal justice system.

Substance abuse can be a “death sentence” for an adolescent with bipolar disorder, Dr. Eist said. Intervention is essential. “We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.”

'We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.' DR. EIST

MENDOZA, ARGENTINA – All comorbid conditions increase the likelihood of substance abuse in adolescents with bipolar disorder, Dr. Harold I. Eist said at the Sixth World Congress on Depressive Disorders.

Many of the traits that characterize adolescence–such as impulsivity, rebelliousness, and curiosity–are intensified in bipolar teens. This is the case particularly in adolescents with comorbid attention-deficit hyperactivity disorder, said Dr. Eist, a psychiatrist in private practice in Bethesda, Md., and a past president of the American Psychiatric Association.

Furthermore, comorbidities such as conduct disorder or severe anxiety further exacerbate the condition, and some adolescents find it extremely difficult to resist the temptation of experimenting with substances.

Nearly 60% of the cases of bipolar disorder begin before the patient is 20 years old. Depending on the age of onset, adolescent bipolar disorder may look like childhood bipolar or adult bipolar disorder. Later-developing mania in adolescents is more likely to be euphoric, biphasic, and episodic, similar to adult mania.

Bipolar disorder in younger adolescents tends to be nonepisodic, chronic, and rapidly cycling, often ultradian and mixed. Early-onset bipolar disorder is characterized by severe irritability and affective storms, which are often violent. Euthymia is rare in early-onset bipolar disorder but common in the late-onset type.

In adolescents with early-onset bipolar disorder, 90% have ADHD, compared with 60% of adolescents who have later-occurring bipolar disorder.

Dr. Eist noted that adolescents with bipolar disorder who have had a significant manic episode will be less effective in school than they were before, and they won't know why. “These disorders are significant and should not be treated as if they were just aberrations of mood.”

The amount of time that an adolescent with bipolar disorder spends in mania or hypomania often is underestimated. Adolescents with bipolar disorder perceive hypomania and mild to moderate mania as normal, and recognize their condition only when they are in full mania. In addition, adolescents with bipolar disorder may experience euthymia as dull or boring.

It is important to keep in mind that adolescents are bad reporters, Dr. Eist said. “When they are depressed, they experience the depression as all consuming. They believe they have always been depressed and always will be depressed.” Adolescents with bipolar disorder are reluctant to keep mood charts, and if they do keep them, they are unlikely to be accurate. An independent assessment of the patient's mood is essential.

Protective factors in treating adolescents with bipolar disorder include positive support of an intact family, patient acceptance of psychotherapy and medication, patient cooperation with long-term therapy, high IQ, and little or no contact with the criminal justice system.

Substance abuse can be a “death sentence” for an adolescent with bipolar disorder, Dr. Eist said. Intervention is essential. “We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.”

'We keep treating the mania, but if we can't get the substance abuse problem under control, we lose the child.' DR. EIST

BUENOS AIRES — Overweight men with chronic or subacute lower back pain can reduce pain intensity and improve overall quality of life by losing weight and exercising daily, according to the results of a study reported by Dr. Eiichhiro Nakamura at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

Dr. Nakamura and colleagues conducted a clinical trial to investigate the effect of lifestyle change, specifically diet and exercise, on overweight men with lower back pain. The trial was based on a previous cohort study by the same investigators, which had shown that overweight and inactive employees had a higher risk of low back pain than did physically active employees who were not overweight, said Dr. Nakamura of the orthopedic surgery department at the University of Occupational and Environmental Health, Kitakyushu, Japan.

In the current study, the researchers screened 2,521 male company employees, and identified 682 men whose body mass index (BMI) at their annual physical examination was 24 kg/m

A total of 44 subjects met the inclusion and exclusion criteria. These subjects were randomized to the intervention group (23 people) or the control group (21 people).

At baseline, subjects in the intervention group participated in an educational session on nutrition and were shown general back and abdominal muscle exercises. They were instructed to perform 2 sets of 20 repetitions of each exercise every day, and to keep a diary for 2 months, in which they reported their daily exercise frequency and body weight. They received a letter of support at weeks 2 and 4. Control subjects were given guidance on good and bad workplace posture.

Both groups completed a questionnaire at weeks 4 and 8 concerning job status; history of low back pain; physical status including height, weight, waist circumference, and BMI; and lifestyle, particularly diet, alcohol consumption, and exercise. All subjects underwent a physical examination at the final study visit at week 8.

Self-reported pain intensity in daily life and at work was assessed using the visual analog scale (VAS), and disability was assessed using the Roland-Morris Disability Questionnaire (RDQ). The Short Form 36 questionnaire (SF-36 v2) was used to assess overall health status. There were no significant differences between the intervention and control groups at baseline.

At 2 months, 22 subjects in the intervention group and 19 in the control group were available for follow-up, Dr. Nakamura reported. The change in BMI from baseline was significantly different between the groups. In addition, waist circumference fell significantly from baseline in the intervention group but not in the control group.

Significant differences between the two groups also were seen in mean change in SF-36 domain scores for vitality and social function. Comparison of baseline and 2-month scores in the intervention group showed significant changes for general health, vitality, and social function, as well as for bodily pain.

Significant improvements from baseline were seen in mean values of VAS scores in both daily life and work in the intervention group, but not in the control group. A significant correlation was found between the reduction of waist circumference and improvement in VAS scores.

Significant improvements in pain intensity were seen in the intervention group, but not the control group. DR. NAKAMURA

BUENOS AIRES — Overweight men with chronic or subacute lower back pain can reduce pain intensity and improve overall quality of life by losing weight and exercising daily, according to the results of a study reported by Dr. Eiichhiro Nakamura at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

Dr. Nakamura and colleagues conducted a clinical trial to investigate the effect of lifestyle change, specifically diet and exercise, on overweight men with lower back pain. The trial was based on a previous cohort study by the same investigators, which had shown that overweight and inactive employees had a higher risk of low back pain than did physically active employees who were not overweight, said Dr. Nakamura of the orthopedic surgery department at the University of Occupational and Environmental Health, Kitakyushu, Japan.

In the current study, the researchers screened 2,521 male company employees, and identified 682 men whose body mass index (BMI) at their annual physical examination was 24 kg/m

A total of 44 subjects met the inclusion and exclusion criteria. These subjects were randomized to the intervention group (23 people) or the control group (21 people).

At baseline, subjects in the intervention group participated in an educational session on nutrition and were shown general back and abdominal muscle exercises. They were instructed to perform 2 sets of 20 repetitions of each exercise every day, and to keep a diary for 2 months, in which they reported their daily exercise frequency and body weight. They received a letter of support at weeks 2 and 4. Control subjects were given guidance on good and bad workplace posture.

Both groups completed a questionnaire at weeks 4 and 8 concerning job status; history of low back pain; physical status including height, weight, waist circumference, and BMI; and lifestyle, particularly diet, alcohol consumption, and exercise. All subjects underwent a physical examination at the final study visit at week 8.

Self-reported pain intensity in daily life and at work was assessed using the visual analog scale (VAS), and disability was assessed using the Roland-Morris Disability Questionnaire (RDQ). The Short Form 36 questionnaire (SF-36 v2) was used to assess overall health status. There were no significant differences between the intervention and control groups at baseline.

At 2 months, 22 subjects in the intervention group and 19 in the control group were available for follow-up, Dr. Nakamura reported. The change in BMI from baseline was significantly different between the groups. In addition, waist circumference fell significantly from baseline in the intervention group but not in the control group.

Significant differences between the two groups also were seen in mean change in SF-36 domain scores for vitality and social function. Comparison of baseline and 2-month scores in the intervention group showed significant changes for general health, vitality, and social function, as well as for bodily pain.

Significant improvements from baseline were seen in mean values of VAS scores in both daily life and work in the intervention group, but not in the control group. A significant correlation was found between the reduction of waist circumference and improvement in VAS scores.

Significant improvements in pain intensity were seen in the intervention group, but not the control group. DR. NAKAMURA

BUENOS AIRES — Overweight men with chronic or subacute lower back pain can reduce pain intensity and improve overall quality of life by losing weight and exercising daily, according to the results of a study reported by Dr. Eiichhiro Nakamura at the annual conference of the International Society of Orthopaedic Surgery and Traumatology.

Dr. Nakamura and colleagues conducted a clinical trial to investigate the effect of lifestyle change, specifically diet and exercise, on overweight men with lower back pain. The trial was based on a previous cohort study by the same investigators, which had shown that overweight and inactive employees had a higher risk of low back pain than did physically active employees who were not overweight, said Dr. Nakamura of the orthopedic surgery department at the University of Occupational and Environmental Health, Kitakyushu, Japan.

In the current study, the researchers screened 2,521 male company employees, and identified 682 men whose body mass index (BMI) at their annual physical examination was 24 kg/m

A total of 44 subjects met the inclusion and exclusion criteria. These subjects were randomized to the intervention group (23 people) or the control group (21 people).

At baseline, subjects in the intervention group participated in an educational session on nutrition and were shown general back and abdominal muscle exercises. They were instructed to perform 2 sets of 20 repetitions of each exercise every day, and to keep a diary for 2 months, in which they reported their daily exercise frequency and body weight. They received a letter of support at weeks 2 and 4. Control subjects were given guidance on good and bad workplace posture.

Both groups completed a questionnaire at weeks 4 and 8 concerning job status; history of low back pain; physical status including height, weight, waist circumference, and BMI; and lifestyle, particularly diet, alcohol consumption, and exercise. All subjects underwent a physical examination at the final study visit at week 8.

Self-reported pain intensity in daily life and at work was assessed using the visual analog scale (VAS), and disability was assessed using the Roland-Morris Disability Questionnaire (RDQ). The Short Form 36 questionnaire (SF-36 v2) was used to assess overall health status. There were no significant differences between the intervention and control groups at baseline.

At 2 months, 22 subjects in the intervention group and 19 in the control group were available for follow-up, Dr. Nakamura reported. The change in BMI from baseline was significantly different between the groups. In addition, waist circumference fell significantly from baseline in the intervention group but not in the control group.

Significant differences between the two groups also were seen in mean change in SF-36 domain scores for vitality and social function. Comparison of baseline and 2-month scores in the intervention group showed significant changes for general health, vitality, and social function, as well as for bodily pain.

Significant improvements from baseline were seen in mean values of VAS scores in both daily life and work in the intervention group, but not in the control group. A significant correlation was found between the reduction of waist circumference and improvement in VAS scores.

Significant improvements in pain intensity were seen in the intervention group, but not the control group. DR. NAKAMURA