Susan London

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes may improve glycemic control, according to observational study results.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycocylated hemoglobin (HbA_1c) rose significantly when patients had OSA, she said.

Dr. Aronsohn, an endocrinology fellow at the University of Chicago, and colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients (54%) were women, and 29 (54%) were black.

Overall, 76% of the patients had OSA, which was classified as mild in 35%, moderate in 26%, and severe in 15%. Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders, mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

The results of studies on continuous positive airway pressure treatment and glycemic control in type 2 diabetes have been confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control,” said Dr. Aronsohn, who reported having no conflicts of interest.

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes may improve glycemic control, according to observational study results.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycocylated hemoglobin (HbA_1c) rose significantly when patients had OSA, she said.

Dr. Aronsohn, an endocrinology fellow at the University of Chicago, and colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients (54%) were women, and 29 (54%) were black.

Overall, 76% of the patients had OSA, which was classified as mild in 35%, moderate in 26%, and severe in 15%. Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders, mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

The results of studies on continuous positive airway pressure treatment and glycemic control in type 2 diabetes have been confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control,” said Dr. Aronsohn, who reported having no conflicts of interest.

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes may improve glycemic control, according to observational study results.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycocylated hemoglobin (HbA_1c) rose significantly when patients had OSA, she said.

Dr. Aronsohn, an endocrinology fellow at the University of Chicago, and colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients (54%) were women, and 29 (54%) were black.

Overall, 76% of the patients had OSA, which was classified as mild in 35%, moderate in 26%, and severe in 15%. Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders, mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

The results of studies on continuous positive airway pressure treatment and glycemic control in type 2 diabetes have been confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control,” said Dr. Aronsohn, who reported having no conflicts of interest.

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

SEATTLE – Returning military veterans who have posttraumatic stress disorder often also have sleep disturbances that may provide an alternative, stigma-free entry into medical care, Anne Germain, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

About 1.6 million people have been deployed to Afghanistan and Iraq as part of the current combat operations in those countries, noted Dr. Germain, an assistant professor of psychiatry at the University of Pittsburgh.

Roughly one-third have been deployed multiple times.

“We know that the risk of PTSD increases with each deployment,” she said. “So whatever estimates we have right now for PTSD, we are likely to see an increase with the number of deployments and duration of tours.”

Deployment has been associated with an increased prevalence of PTSD, Dr. Germain noted.

For example, 5% of Army personnel meet criteria for PTSD before deploying to Iraq, compared with almost 13% after their return (N. Engl. J. Med. 2004;351:13-22).

Three other psychiatric disorders–anxiety, depression, and alcohol misuse–also become more prevalent after deployment.

“All of these disorders are associated with stigma,” she observed. “Despite the military's best effort to destigmatize mental health difficulties post deployment, a lot of people will refuse or be very hesitant to seek care for these conditions.”

However, all of the disorders are also associated with sleep disturbances, including insomnia, irregular sleep-wake schedules, and hypersomnia.

“Sleep disturbances may actually provide an entry into care that is not stigmatizing, that is more socially acceptable, that gets people to seek help first,” she said.

“And once they are in treatment, maybe we can address these other psychiatric difficulties.”

When it comes to the pathogenesis of PTSD and sleep disturbances in returning military personnel, research has implicated both physical and psychological exposures during deployment, according to Dr. Germain.

Her team is specifically investigating the role of blast exposure in a new study that has thus far enrolled 25 military veterans returning from Iraq or Afghanistan who reported sleep difficulties.

Preliminary analyses showed the returnees were an average age of 28 years, and 92% were men. Forty percent had been exposed to a blast during their deployment.

The prevalence of PTSD was higher in the group exposed to blasts than in the nonexposed group (90% vs. 67%).

The groups had nearly equal, moderate levels of insomnia as measured by mean scores on the Insomnia Severity Index, or ISI (16.5 vs. 16.0), and the same poor sleep quality as measured by mean scores on the Pittsburgh Sleep Quality Index, or PSQI (10.7 vs. 10.7).

“These veterans are well within the realm for clinically significant sleep disturbance,” she observed. “Those are levels of sleep disturbances that we treat.”

However, the blast-exposed group had a higher level of disruptive nocturnal behaviors, such as nightmares of traumatic events or dream enactments involving kicking or punching, as measured by mean scores on the PSQI Addendum (PSQI-A), which assesses sleep disturbances associated with PTSD (6.6 vs. 3.9).

“What this means is unclear at this time,” Dr. Germain commented. “But it's definitely something that we want to follow up, because the treatments for these types of sleep disturbances are very different from those that we typically use for insomnia, for example.”

Blast-exposed and -nonexposed returnees were similar in terms of sleep diary and polysomnography measures. However, she noted, the polysomnography data might have been confounded by the high prevalence of PTSD.

“When veterans with PTSD sleep in the sleep lab, they sleep much better. They feel safe; there is somebody watching them,” she explained.

“So usually they catch up on sleep a little bit, and their sleep efficiency is better.”

Dr. Germain cautioned that definitive study results will require a larger sample size, as well as follow-up to assess the course of the sleep disturbances and PTSD, and the impact of treatment in the blast-exposed and -nonexposed groups.

“I'm especially interested in looking at how sleep may play a role in the development of some of those mental health difficulties or adjustment difficulties–not just PTSD, but other difficulties, too, such as depression–and in looking at the role of sleep in recovery as well,” she said.

Dr. Germain reported that she had no conflicts of interest in association with her presentation.

When veterans with PTSD sleep in the lab, they sleep much better. They feel safe; somebody is watching them.

Source DR. GERMAIN

SEATTLE – Female Native American adolescents undergoing mandated chemical dependency treatment were significantly more likely than their male counterparts to complete such programs, a retrospective study found.

Results of the study were presented by Dr. Christopher M. Davidson and Dr. Michael C. Harlow, both forensic psychiatrists at the University of South Dakota, Sioux Falls, at the annual meeting of the American Academy of Psychiatry and the Law.

Dr. Davidson said treatment success rates tend to be low in addiction treatment, and information on minorities, particularly Native Americans, is sparse. They found that 74.5% of boys and 87.1% of girls completed treatment. Identifying factors associated with a reduced likelihood of treatment completion is an initial step toward improving this outcome, he noted.

The investigators reviewed the charts of 203 Native American adolescents who had undergone mandated treatment for chemical dependency at a South Dakota inpatient treatment center.

They determined each adolescent's criminal history, prior addiction treatment, mental health, and substance use, as assessed with the DSM-IV interview, the Million Adolescent Clinical Inventory (MACI), the Substance Abuse Subtle Screening Inventory (SASSI-A2), the Michigan Alcohol Screening Test (MAST), and the Drug Abuse Screening Test (DAST).

Study results indicated that the adolescents came from 13 states. Slightly more than half were male, and their mean age was 16 years. For 53% of the youth, treatment had been mandated by a court order; for the rest, it had been mandated by their tribal council or a precourt legal agreement. Half had been treated for addiction before. The mean age at first contact with the law was 11 years. Seventy percent had been previously arrested for drug-related offenses, and 35% had been arrested for violent crimes.

Fully 80% of the adolescents successfully completed the chemical dependency treatment program–a rate much higher than the national average. “This treatment facility has culturally specific programs for Native Americans, which we believe probably makes a difference,” Dr. Davidson said.

One of the findings proved surprising, said Dr. Harlow. “There was no correlation between having [court-ordered] treatment, having a previous treatment history, or having an arrest history, and their chances of successfully completing treatment,” he said.

Study results also showed high levels of comorbidities in the adolescents. For example, according to MACI scores, large proportions had Axis I findings, most commonly conduct disorder (49%), dysthymia (35%), disruptive behavior disorder (22%), parent-child relational problems (21%), and physical abuse (10%). In addition, the majority had Axis II features and traits, particularly an antisocial personality (60%), and a negativistic or passive-aggressive personality (51%).

“Once we figure out the issues that Native Americans face as far as succeeding in [mandated] treatment, we can hopefully tailor programming to optimize their chances of success,” Dr. Harlow said.

The investigators plan to compare the findings with those in a matched group of non-Native American adolescents and also study the same issues among Native American adults in chemical dependency treatment.

Dr. Davidson and Dr. Harlow reported that they had no conflicts of interest in association with the study.

SEATTLE – Female Native American adolescents undergoing mandated chemical dependency treatment were significantly more likely than their male counterparts to complete such programs, a retrospective study found.

Results of the study were presented by Dr. Christopher M. Davidson and Dr. Michael C. Harlow, both forensic psychiatrists at the University of South Dakota, Sioux Falls, at the annual meeting of the American Academy of Psychiatry and the Law.

Dr. Davidson said treatment success rates tend to be low in addiction treatment, and information on minorities, particularly Native Americans, is sparse. They found that 74.5% of boys and 87.1% of girls completed treatment. Identifying factors associated with a reduced likelihood of treatment completion is an initial step toward improving this outcome, he noted.

The investigators reviewed the charts of 203 Native American adolescents who had undergone mandated treatment for chemical dependency at a South Dakota inpatient treatment center.

They determined each adolescent's criminal history, prior addiction treatment, mental health, and substance use, as assessed with the DSM-IV interview, the Million Adolescent Clinical Inventory (MACI), the Substance Abuse Subtle Screening Inventory (SASSI-A2), the Michigan Alcohol Screening Test (MAST), and the Drug Abuse Screening Test (DAST).

Study results indicated that the adolescents came from 13 states. Slightly more than half were male, and their mean age was 16 years. For 53% of the youth, treatment had been mandated by a court order; for the rest, it had been mandated by their tribal council or a precourt legal agreement. Half had been treated for addiction before. The mean age at first contact with the law was 11 years. Seventy percent had been previously arrested for drug-related offenses, and 35% had been arrested for violent crimes.

Fully 80% of the adolescents successfully completed the chemical dependency treatment program–a rate much higher than the national average. “This treatment facility has culturally specific programs for Native Americans, which we believe probably makes a difference,” Dr. Davidson said.

One of the findings proved surprising, said Dr. Harlow. “There was no correlation between having [court-ordered] treatment, having a previous treatment history, or having an arrest history, and their chances of successfully completing treatment,” he said.

Study results also showed high levels of comorbidities in the adolescents. For example, according to MACI scores, large proportions had Axis I findings, most commonly conduct disorder (49%), dysthymia (35%), disruptive behavior disorder (22%), parent-child relational problems (21%), and physical abuse (10%). In addition, the majority had Axis II features and traits, particularly an antisocial personality (60%), and a negativistic or passive-aggressive personality (51%).

“Once we figure out the issues that Native Americans face as far as succeeding in [mandated] treatment, we can hopefully tailor programming to optimize their chances of success,” Dr. Harlow said.

The investigators plan to compare the findings with those in a matched group of non-Native American adolescents and also study the same issues among Native American adults in chemical dependency treatment.

Dr. Davidson and Dr. Harlow reported that they had no conflicts of interest in association with the study.

SEATTLE – Female Native American adolescents undergoing mandated chemical dependency treatment were significantly more likely than their male counterparts to complete such programs, a retrospective study found.

Results of the study were presented by Dr. Christopher M. Davidson and Dr. Michael C. Harlow, both forensic psychiatrists at the University of South Dakota, Sioux Falls, at the annual meeting of the American Academy of Psychiatry and the Law.

Dr. Davidson said treatment success rates tend to be low in addiction treatment, and information on minorities, particularly Native Americans, is sparse. They found that 74.5% of boys and 87.1% of girls completed treatment. Identifying factors associated with a reduced likelihood of treatment completion is an initial step toward improving this outcome, he noted.

The investigators reviewed the charts of 203 Native American adolescents who had undergone mandated treatment for chemical dependency at a South Dakota inpatient treatment center.

They determined each adolescent's criminal history, prior addiction treatment, mental health, and substance use, as assessed with the DSM-IV interview, the Million Adolescent Clinical Inventory (MACI), the Substance Abuse Subtle Screening Inventory (SASSI-A2), the Michigan Alcohol Screening Test (MAST), and the Drug Abuse Screening Test (DAST).

Study results indicated that the adolescents came from 13 states. Slightly more than half were male, and their mean age was 16 years. For 53% of the youth, treatment had been mandated by a court order; for the rest, it had been mandated by their tribal council or a precourt legal agreement. Half had been treated for addiction before. The mean age at first contact with the law was 11 years. Seventy percent had been previously arrested for drug-related offenses, and 35% had been arrested for violent crimes.

Fully 80% of the adolescents successfully completed the chemical dependency treatment program–a rate much higher than the national average. “This treatment facility has culturally specific programs for Native Americans, which we believe probably makes a difference,” Dr. Davidson said.

One of the findings proved surprising, said Dr. Harlow. “There was no correlation between having [court-ordered] treatment, having a previous treatment history, or having an arrest history, and their chances of successfully completing treatment,” he said.

Study results also showed high levels of comorbidities in the adolescents. For example, according to MACI scores, large proportions had Axis I findings, most commonly conduct disorder (49%), dysthymia (35%), disruptive behavior disorder (22%), parent-child relational problems (21%), and physical abuse (10%). In addition, the majority had Axis II features and traits, particularly an antisocial personality (60%), and a negativistic or passive-aggressive personality (51%).

“Once we figure out the issues that Native Americans face as far as succeeding in [mandated] treatment, we can hopefully tailor programming to optimize their chances of success,” Dr. Harlow said.

The investigators plan to compare the findings with those in a matched group of non-Native American adolescents and also study the same issues among Native American adults in chemical dependency treatment.

Dr. Davidson and Dr. Harlow reported that they had no conflicts of interest in association with the study.

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

"It's such a black hole, a lot of clinicians just don't want to think about it." But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. "When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition," he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off for vasculitis. "Why should a kid be peeing blood and coughing up blood?" he said. "That's two different organs." Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution, typically with crossing over the bridge of the nose and spreading onto the cheeks, and a well-defined border between the affected skin and normal skin. Children with malar rashes usually have other symptoms or clinical findings too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. "You need to look up to see the hard palate," he pointed out. "If you look at the back of the throat, you will miss this."

Discoid rash is less common and causes crusts or scabs that scar. "If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath." he said. "Discoid lupus especially likes the helix of the ear, so pay attention to the helix."

Children also may have so-called lupus hairs, which are fragile and break easily. "You pull on their hair, you get three, four, or five hairs, even if they just brushed it," he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep venous thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely 1.

In fact, he cautioned, 12%-20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. "If the panel is negative, you can cool your jets and cool the mom's jets," he said.

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. "We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too," Dr. Sherry said.

"The outcome of most kids with lupus is certainly not what it used to be," he said. "More than 90% of our kids do very well and have long-term survival."

In fact, "now that we are saving these kids, we have to worry about the side effects of treatment." Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

The spotty malar rash associated with lupus can mimic rosacea.

This lupus patient's rash is largely confined to the nose.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

Source Photos courtesy Dr. David Sherry

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

"It's such a black hole, a lot of clinicians just don't want to think about it." But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. "When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition," he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off for vasculitis. "Why should a kid be peeing blood and coughing up blood?" he said. "That's two different organs." Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution, typically with crossing over the bridge of the nose and spreading onto the cheeks, and a well-defined border between the affected skin and normal skin. Children with malar rashes usually have other symptoms or clinical findings too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. "You need to look up to see the hard palate," he pointed out. "If you look at the back of the throat, you will miss this."

Discoid rash is less common and causes crusts or scabs that scar. "If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath." he said. "Discoid lupus especially likes the helix of the ear, so pay attention to the helix."

Children also may have so-called lupus hairs, which are fragile and break easily. "You pull on their hair, you get three, four, or five hairs, even if they just brushed it," he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep venous thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely 1.

In fact, he cautioned, 12%-20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. "If the panel is negative, you can cool your jets and cool the mom's jets," he said.

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. "We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too," Dr. Sherry said.

"The outcome of most kids with lupus is certainly not what it used to be," he said. "More than 90% of our kids do very well and have long-term survival."

In fact, "now that we are saving these kids, we have to worry about the side effects of treatment." Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

The spotty malar rash associated with lupus can mimic rosacea.

This lupus patient's rash is largely confined to the nose.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

Source Photos courtesy Dr. David Sherry

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

"It's such a black hole, a lot of clinicians just don't want to think about it." But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. "When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition," he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off for vasculitis. "Why should a kid be peeing blood and coughing up blood?" he said. "That's two different organs." Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution, typically with crossing over the bridge of the nose and spreading onto the cheeks, and a well-defined border between the affected skin and normal skin. Children with malar rashes usually have other symptoms or clinical findings too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. "You need to look up to see the hard palate," he pointed out. "If you look at the back of the throat, you will miss this."

Discoid rash is less common and causes crusts or scabs that scar. "If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath." he said. "Discoid lupus especially likes the helix of the ear, so pay attention to the helix."

Children also may have so-called lupus hairs, which are fragile and break easily. "You pull on their hair, you get three, four, or five hairs, even if they just brushed it," he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep venous thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely 1.

In fact, he cautioned, 12%-20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. "If the panel is negative, you can cool your jets and cool the mom's jets," he said.

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. "We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too," Dr. Sherry said.

"The outcome of most kids with lupus is certainly not what it used to be," he said. "More than 90% of our kids do very well and have long-term survival."

In fact, "now that we are saving these kids, we have to worry about the side effects of treatment." Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

The spotty malar rash associated with lupus can mimic rosacea.

This lupus patient's rash is largely confined to the nose.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

Source Photos courtesy Dr. David Sherry

SEATTLE — Teaching children and their parents about sun safety is the best way to reduce the risk of melanoma both during childhood and later in life, according to Dr. Annette M. Wagner, a pediatric dermatologist at Northwestern University in Chicago.

"There is an epidemic of melanoma," she said at a meeting sponsored by the American Academy of Pediatrics, noting that the incidence is rising among both pediatric and adult populations. "Just because you see only children, do not believe you don't have to worry."

Adolescents should be counseled about the deadliness of melanoma, Dr. Wagner advised.

"They don't know how dangerous this is," she said. "Every one of them believes that parents who smoke cigarettes are crazy because that can cause lung cancer. But they don't know that they are at more risk of getting a melanoma from going in the tanning booth than their parents ever were of getting lung cancer from smoking."

Pediatricians also should teach all children, starting at a young age, about wearing sunscreen daily.

"When you are doing your general care for pediatric patients, just like you talk about brushing teeth and wearing seat belts, you have got to teach them to put on sunscreen," Dr. Wagner noted. "If you teach a child under the age of 2 to wear sunscreen, they will wear it every day."

Sunscreens with a sun protection factor (SPF) greater than 30 provide minimal additional protection against solar radiation, compared with those with an SPF of 30, Dr. Wagner noted. If anything, suncreens with an SPF greater than 30 are likely to contain a greater number of chemicals that can be irritants.

She advocated choosing sunscreens that contain only a physical radiation blocker—zinc oxide or titanium dioxide—often marketed as chemical-free sunscreens. "They are not hard on sensitive skin, they don't sting or burn when you rub them into your eyes, and they are much better tolerated in the pediatric population," she explained.

"You can and should put sunscreen on all infants who are outside," she continued, even those younger than 6 months of age. However, clothing remains the best form of sunscreen for young infants, if it can provide adequate protection.

Recent concerns about vitamin D deficiency should be addressed with a multivitamin supplement containing this vitamin, she said. "I would never, ever use concerns about vitamin D as an excuse for not using sunscreen."

When it comes to moles, educating parents and children about warning signs is key, said Dr. Wagner. The A, B, C, D's of melanoma—asymmetry, border irregularity, color variation, and diameter greater than 6 mm—are not very helpful in the pediatric population because children tend to get monomorphous moles that all look alike.

Therefore, when trying to determine which moles to worry about in younger children, she recommended using the Ugly Duckling or Sesame Street rule: "It's that one mole that does not look like the others, and therefore it does not belong."

Although a black lesion is what most often comes to mind with melanoma, this cancer often has a different appearance in children.

"The most common presentation of a melanoma in a child is a rapidly growing pink papule," Dr. Wagner emphasized. And these papules may resemble Spitz nevi, so "don't ever ignore a Spitz nevus on a child."

In the pediatric population, moles that itch or bleed are generally not worrisome, unless the bleeding is spontaneous, she said. But size is important. "If you have a mole in a child at any age that is smaller than their thumbnail, the risk of melanoma is less than 1%, and that mole probably does not require anything but observation," she said. Larger moles require a referral to a specialist.

Dr. Wagner reported that she had no conflicts of interest relevant to her presentation.

SEATTLE — Teaching children and their parents about sun safety is the best way to reduce the risk of melanoma both during childhood and later in life, according to Dr. Annette M. Wagner, a pediatric dermatologist at Northwestern University in Chicago.

"There is an epidemic of melanoma," she said at a meeting sponsored by the American Academy of Pediatrics, noting that the incidence is rising among both pediatric and adult populations. "Just because you see only children, do not believe you don't have to worry."

Adolescents should be counseled about the deadliness of melanoma, Dr. Wagner advised.

"They don't know how dangerous this is," she said. "Every one of them believes that parents who smoke cigarettes are crazy because that can cause lung cancer. But they don't know that they are at more risk of getting a melanoma from going in the tanning booth than their parents ever were of getting lung cancer from smoking."

Pediatricians also should teach all children, starting at a young age, about wearing sunscreen daily.

"When you are doing your general care for pediatric patients, just like you talk about brushing teeth and wearing seat belts, you have got to teach them to put on sunscreen," Dr. Wagner noted. "If you teach a child under the age of 2 to wear sunscreen, they will wear it every day."

Sunscreens with a sun protection factor (SPF) greater than 30 provide minimal additional protection against solar radiation, compared with those with an SPF of 30, Dr. Wagner noted. If anything, suncreens with an SPF greater than 30 are likely to contain a greater number of chemicals that can be irritants.

She advocated choosing sunscreens that contain only a physical radiation blocker—zinc oxide or titanium dioxide—often marketed as chemical-free sunscreens. "They are not hard on sensitive skin, they don't sting or burn when you rub them into your eyes, and they are much better tolerated in the pediatric population," she explained.

"You can and should put sunscreen on all infants who are outside," she continued, even those younger than 6 months of age. However, clothing remains the best form of sunscreen for young infants, if it can provide adequate protection.

Recent concerns about vitamin D deficiency should be addressed with a multivitamin supplement containing this vitamin, she said. "I would never, ever use concerns about vitamin D as an excuse for not using sunscreen."

When it comes to moles, educating parents and children about warning signs is key, said Dr. Wagner. The A, B, C, D's of melanoma—asymmetry, border irregularity, color variation, and diameter greater than 6 mm—are not very helpful in the pediatric population because children tend to get monomorphous moles that all look alike.

Therefore, when trying to determine which moles to worry about in younger children, she recommended using the Ugly Duckling or Sesame Street rule: "It's that one mole that does not look like the others, and therefore it does not belong."

Although a black lesion is what most often comes to mind with melanoma, this cancer often has a different appearance in children.

"The most common presentation of a melanoma in a child is a rapidly growing pink papule," Dr. Wagner emphasized. And these papules may resemble Spitz nevi, so "don't ever ignore a Spitz nevus on a child."

In the pediatric population, moles that itch or bleed are generally not worrisome, unless the bleeding is spontaneous, she said. But size is important. "If you have a mole in a child at any age that is smaller than their thumbnail, the risk of melanoma is less than 1%, and that mole probably does not require anything but observation," she said. Larger moles require a referral to a specialist.

Dr. Wagner reported that she had no conflicts of interest relevant to her presentation.

SEATTLE — Teaching children and their parents about sun safety is the best way to reduce the risk of melanoma both during childhood and later in life, according to Dr. Annette M. Wagner, a pediatric dermatologist at Northwestern University in Chicago.

"There is an epidemic of melanoma," she said at a meeting sponsored by the American Academy of Pediatrics, noting that the incidence is rising among both pediatric and adult populations. "Just because you see only children, do not believe you don't have to worry."

Adolescents should be counseled about the deadliness of melanoma, Dr. Wagner advised.

"They don't know how dangerous this is," she said. "Every one of them believes that parents who smoke cigarettes are crazy because that can cause lung cancer. But they don't know that they are at more risk of getting a melanoma from going in the tanning booth than their parents ever were of getting lung cancer from smoking."

Pediatricians also should teach all children, starting at a young age, about wearing sunscreen daily.

"When you are doing your general care for pediatric patients, just like you talk about brushing teeth and wearing seat belts, you have got to teach them to put on sunscreen," Dr. Wagner noted. "If you teach a child under the age of 2 to wear sunscreen, they will wear it every day."

Sunscreens with a sun protection factor (SPF) greater than 30 provide minimal additional protection against solar radiation, compared with those with an SPF of 30, Dr. Wagner noted. If anything, suncreens with an SPF greater than 30 are likely to contain a greater number of chemicals that can be irritants.

She advocated choosing sunscreens that contain only a physical radiation blocker—zinc oxide or titanium dioxide—often marketed as chemical-free sunscreens. "They are not hard on sensitive skin, they don't sting or burn when you rub them into your eyes, and they are much better tolerated in the pediatric population," she explained.

"You can and should put sunscreen on all infants who are outside," she continued, even those younger than 6 months of age. However, clothing remains the best form of sunscreen for young infants, if it can provide adequate protection.

Recent concerns about vitamin D deficiency should be addressed with a multivitamin supplement containing this vitamin, she said. "I would never, ever use concerns about vitamin D as an excuse for not using sunscreen."

When it comes to moles, educating parents and children about warning signs is key, said Dr. Wagner. The A, B, C, D's of melanoma—asymmetry, border irregularity, color variation, and diameter greater than 6 mm—are not very helpful in the pediatric population because children tend to get monomorphous moles that all look alike.

Therefore, when trying to determine which moles to worry about in younger children, she recommended using the Ugly Duckling or Sesame Street rule: "It's that one mole that does not look like the others, and therefore it does not belong."

Although a black lesion is what most often comes to mind with melanoma, this cancer often has a different appearance in children.

"The most common presentation of a melanoma in a child is a rapidly growing pink papule," Dr. Wagner emphasized. And these papules may resemble Spitz nevi, so "don't ever ignore a Spitz nevus on a child."

In the pediatric population, moles that itch or bleed are generally not worrisome, unless the bleeding is spontaneous, she said. But size is important. "If you have a mole in a child at any age that is smaller than their thumbnail, the risk of melanoma is less than 1%, and that mole probably does not require anything but observation," she said. Larger moles require a referral to a specialist.

Dr. Wagner reported that she had no conflicts of interest relevant to her presentation.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said.

“This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few,” she added.

In the study, Ms. McChesney, a nursing student at the University of Calgary, Alta., and her colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

“Future studies are needed to determine the individual effects of the newer AEDs on bone health in this age group and to elucidate the mechanism of this association,” she concluded.

Ms. McChesney reported that she had no disclosures to make in relation to the study.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said.

“This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few,” she added.

In the study, Ms. McChesney, a nursing student at the University of Calgary, Alta., and her colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

“Future studies are needed to determine the individual effects of the newer AEDs on bone health in this age group and to elucidate the mechanism of this association,” she concluded.

Ms. McChesney reported that she had no disclosures to make in relation to the study.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said.

“This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few,” she added.

In the study, Ms. McChesney, a nursing student at the University of Calgary, Alta., and her colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

“Future studies are needed to determine the individual effects of the newer AEDs on bone health in this age group and to elucidate the mechanism of this association,” she concluded.

Ms. McChesney reported that she had no disclosures to make in relation to the study.

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, such as Tripedia (diphtheria, tetanus, and acellular pertussis), Fluzone (influenza), Zostavax (zoster), and Varivax (varicella), said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego.

In Japan, where anaphylactic reactions to vaccines became common, gelatin has been removed from vaccines or hydrolyzed more thoroughly to make it less allergenic, he noted. But vaccines have not been so altered in the United States.

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted.

For information on the components of vaccines, go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/?appendices/B/excipient-table-2.pdf

Dr. Kelso reported no conflicts of interest related to his presentation.

If the allergy is confirmed, an allergist can administer the vaccine using strategies such as graded dosing. DR. KELSO

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, such as Tripedia (diphtheria, tetanus, and acellular pertussis), Fluzone (influenza), Zostavax (zoster), and Varivax (varicella), said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego.

In Japan, where anaphylactic reactions to vaccines became common, gelatin has been removed from vaccines or hydrolyzed more thoroughly to make it less allergenic, he noted. But vaccines have not been so altered in the United States.

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted.

For information on the components of vaccines, go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/?appendices/B/excipient-table-2.pdf

Dr. Kelso reported no conflicts of interest related to his presentation.

If the allergy is confirmed, an allergist can administer the vaccine using strategies such as graded dosing. DR. KELSO

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, such as Tripedia (diphtheria, tetanus, and acellular pertussis), Fluzone (influenza), Zostavax (zoster), and Varivax (varicella), said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego.

In Japan, where anaphylactic reactions to vaccines became common, gelatin has been removed from vaccines or hydrolyzed more thoroughly to make it less allergenic, he noted. But vaccines have not been so altered in the United States.

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted.

For information on the components of vaccines, go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/?appendices/B/excipient-table-2.pdf

Dr. Kelso reported no conflicts of interest related to his presentation.

If the allergy is confirmed, an allergist can administer the vaccine using strategies such as graded dosing. DR. KELSO

SEATTLE — Magnetic resonance imaging performed in the first year or two of parkinsonism seldom yields information useful for establishing the diagnosis.

The final diagnosis in patients with parkinsonism may remain uncertain for years and has historically relied on clinical evaluation and follow-up, lead author Dr. Marie-Josée Langlois said at a poster presentation at the annual meeting of the American Academy of Neurology.

Current guidelines do not specify a clear role for MRI in this setting.

Dr. Langlois and her coinvestigator, Dr. Michel Panisset, both of the University of Montreal, reviewed the charts of consecutive patients with parkinsonism who were evaluated at their institution between 1992 and 2003 and had at least 5 years of follow-up.

Of the 114 patients studied, 25 (22%) had an MRI in the year before or after the initial consultation for parkinsonism. The imaging took place a mean of 1.7 years after the parkinsonism diagnosis.

“Atypical clinical findings and a younger age were the main reasons for doing an MRI,” Dr. Langlois reported. All but two of the imaged patients had findings such as an early onset of falls or a poor response to levodopa, or were aged 50 years or younger.

“We did not find many specific MRI changes,” she said. Of the 25 patients who underwent this imaging, 19 (76%) had normal results, and 6 (24%) had basal ganglia abnormalities.

In the latter group, the abnormalities had a vascular etiology in four patients. Two patients had the same final diagnosis after a mean 6-year follow-up as their initial diagnosis (Parkinson's disease and progressive supranuclear palsy), while two had a change in diagnosis (from focal signs to Parkinson's disease, and from Wilson's disease to Parkinson's disease).

The other two patients with basal ganglia abnormalities on MRI had changes consistent with multiple system atrophy, which was already suspected clinically. In both cases, this initial diagnosis remained unchanged with follow-up.

Overall, in the MRI group, Parkinson's disease (versus atypical or secondary parkinsonism) was the initial diagnosis in 24% of patients and the final diagnosis in 56%. This pattern differed significantly from that in the no-MRI group, which had a mean follow-up of 7 years: Parkinson's disease was the initial diagnosis in 63% of those patients, and the final diagnosis in 76%.

“MRI was not that useful in establishing the initial diagnosis or in changing the diagnosis” in this population with parkinsonism, Dr. Langlois commented.

MRI appears to serve mainly as confirmation of a clinically suspected diagnosis of Parkinson's disease when the results are normal, she noted. “But it may in some cases confirm a clinical diagnosis of atypical parkinsonism, for example, or, if there is a clinical suspicion of a vascular cause, confirm it.”

Other studies that have found higher rates of abnormalities on MRI were conducted in patients who had had parkinsonism for 3.5-5 years, she noted, “so it was not that surprising that with a delay of about 1 year, there is not much change in the MRI.”

However, she added, high-field MRI with fine slices through the basal ganglia and brainstem might reveal changes at such early time points, a possibility that should be explored in a prospective trial.

Dr. Langlois reported that she had no conflicts of interest in relation to the study.

'Atypical clinical findings and a younger age were the main reasons for doing an MRI.' DR. LANGLOIS

SEATTLE — Magnetic resonance imaging performed in the first year or two of parkinsonism seldom yields information useful for establishing the diagnosis.

The final diagnosis in patients with parkinsonism may remain uncertain for years and has historically relied on clinical evaluation and follow-up, lead author Dr. Marie-Josée Langlois said at a poster presentation at the annual meeting of the American Academy of Neurology.

Current guidelines do not specify a clear role for MRI in this setting.

Dr. Langlois and her coinvestigator, Dr. Michel Panisset, both of the University of Montreal, reviewed the charts of consecutive patients with parkinsonism who were evaluated at their institution between 1992 and 2003 and had at least 5 years of follow-up.

Of the 114 patients studied, 25 (22%) had an MRI in the year before or after the initial consultation for parkinsonism. The imaging took place a mean of 1.7 years after the parkinsonism diagnosis.

“Atypical clinical findings and a younger age were the main reasons for doing an MRI,” Dr. Langlois reported. All but two of the imaged patients had findings such as an early onset of falls or a poor response to levodopa, or were aged 50 years or younger.

“We did not find many specific MRI changes,” she said. Of the 25 patients who underwent this imaging, 19 (76%) had normal results, and 6 (24%) had basal ganglia abnormalities.

In the latter group, the abnormalities had a vascular etiology in four patients. Two patients had the same final diagnosis after a mean 6-year follow-up as their initial diagnosis (Parkinson's disease and progressive supranuclear palsy), while two had a change in diagnosis (from focal signs to Parkinson's disease, and from Wilson's disease to Parkinson's disease).

The other two patients with basal ganglia abnormalities on MRI had changes consistent with multiple system atrophy, which was already suspected clinically. In both cases, this initial diagnosis remained unchanged with follow-up.

Overall, in the MRI group, Parkinson's disease (versus atypical or secondary parkinsonism) was the initial diagnosis in 24% of patients and the final diagnosis in 56%. This pattern differed significantly from that in the no-MRI group, which had a mean follow-up of 7 years: Parkinson's disease was the initial diagnosis in 63% of those patients, and the final diagnosis in 76%.

“MRI was not that useful in establishing the initial diagnosis or in changing the diagnosis” in this population with parkinsonism, Dr. Langlois commented.

MRI appears to serve mainly as confirmation of a clinically suspected diagnosis of Parkinson's disease when the results are normal, she noted. “But it may in some cases confirm a clinical diagnosis of atypical parkinsonism, for example, or, if there is a clinical suspicion of a vascular cause, confirm it.”

Other studies that have found higher rates of abnormalities on MRI were conducted in patients who had had parkinsonism for 3.5-5 years, she noted, “so it was not that surprising that with a delay of about 1 year, there is not much change in the MRI.”

However, she added, high-field MRI with fine slices through the basal ganglia and brainstem might reveal changes at such early time points, a possibility that should be explored in a prospective trial.

Dr. Langlois reported that she had no conflicts of interest in relation to the study.

'Atypical clinical findings and a younger age were the main reasons for doing an MRI.' DR. LANGLOIS

SEATTLE — Magnetic resonance imaging performed in the first year or two of parkinsonism seldom yields information useful for establishing the diagnosis.

The final diagnosis in patients with parkinsonism may remain uncertain for years and has historically relied on clinical evaluation and follow-up, lead author Dr. Marie-Josée Langlois said at a poster presentation at the annual meeting of the American Academy of Neurology.

Current guidelines do not specify a clear role for MRI in this setting.

Dr. Langlois and her coinvestigator, Dr. Michel Panisset, both of the University of Montreal, reviewed the charts of consecutive patients with parkinsonism who were evaluated at their institution between 1992 and 2003 and had at least 5 years of follow-up.

Of the 114 patients studied, 25 (22%) had an MRI in the year before or after the initial consultation for parkinsonism. The imaging took place a mean of 1.7 years after the parkinsonism diagnosis.

“Atypical clinical findings and a younger age were the main reasons for doing an MRI,” Dr. Langlois reported. All but two of the imaged patients had findings such as an early onset of falls or a poor response to levodopa, or were aged 50 years or younger.

“We did not find many specific MRI changes,” she said. Of the 25 patients who underwent this imaging, 19 (76%) had normal results, and 6 (24%) had basal ganglia abnormalities.

In the latter group, the abnormalities had a vascular etiology in four patients. Two patients had the same final diagnosis after a mean 6-year follow-up as their initial diagnosis (Parkinson's disease and progressive supranuclear palsy), while two had a change in diagnosis (from focal signs to Parkinson's disease, and from Wilson's disease to Parkinson's disease).

The other two patients with basal ganglia abnormalities on MRI had changes consistent with multiple system atrophy, which was already suspected clinically. In both cases, this initial diagnosis remained unchanged with follow-up.

Overall, in the MRI group, Parkinson's disease (versus atypical or secondary parkinsonism) was the initial diagnosis in 24% of patients and the final diagnosis in 56%. This pattern differed significantly from that in the no-MRI group, which had a mean follow-up of 7 years: Parkinson's disease was the initial diagnosis in 63% of those patients, and the final diagnosis in 76%.

“MRI was not that useful in establishing the initial diagnosis or in changing the diagnosis” in this population with parkinsonism, Dr. Langlois commented.

MRI appears to serve mainly as confirmation of a clinically suspected diagnosis of Parkinson's disease when the results are normal, she noted. “But it may in some cases confirm a clinical diagnosis of atypical parkinsonism, for example, or, if there is a clinical suspicion of a vascular cause, confirm it.”

Other studies that have found higher rates of abnormalities on MRI were conducted in patients who had had parkinsonism for 3.5-5 years, she noted, “so it was not that surprising that with a delay of about 1 year, there is not much change in the MRI.”

However, she added, high-field MRI with fine slices through the basal ganglia and brainstem might reveal changes at such early time points, a possibility that should be explored in a prospective trial.

Dr. Langlois reported that she had no conflicts of interest in relation to the study.

'Atypical clinical findings and a younger age were the main reasons for doing an MRI.' DR. LANGLOIS

SEATTLE — Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate-to-severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology.

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups—the trial's primary end point—was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Patients in the pramipexole group had higher rates of dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), Dr. Barone observed. The rate of serious adverse events was 4% in each group.

Establishing an effective treatment for depression could lead to a reduction in the number of medications needed to effectively manage PD symptoms, said Dr. Barone, who reported receiving research support and consulting fees from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE — Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate-to-severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology.

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups—the trial's primary end point—was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Patients in the pramipexole group had higher rates of dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), Dr. Barone observed. The rate of serious adverse events was 4% in each group.

Establishing an effective treatment for depression could lead to a reduction in the number of medications needed to effectively manage PD symptoms, said Dr. Barone, who reported receiving research support and consulting fees from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE — Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate-to-severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology.

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups—the trial's primary end point—was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Patients in the pramipexole group had higher rates of dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), Dr. Barone observed. The rate of serious adverse events was 4% in each group.

Establishing an effective treatment for depression could lead to a reduction in the number of medications needed to effectively manage PD symptoms, said Dr. Barone, who reported receiving research support and consulting fees from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said. “This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few.”

Ms. McChesney, a nursing student at the University of Calgary, Alta., and colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

Ms. McChesney reported that she had no disclosures to make in relation to the study.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said. “This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few.”

Ms. McChesney, a nursing student at the University of Calgary, Alta., and colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

Ms. McChesney reported that she had no disclosures to make in relation to the study.

SEATTLE — Older adults in the general population have an elevated risk of fractures related to osteoporosis if they take certain antiepileptic drugs, according to a population-based analysis.

“Prior studies have shown that antiepileptic drugs [AEDs] are associated with an increased risk of bone loss and fractures,” presenting author Jane McChesney said at the annual meeting of the American Academy of Neurology. “However, population-based data assessing the association between AEDs and osteoporotic-related fractures are scarce.”

“This study found that AEDs, except for fatty acid derivatives, are associated with an increased risk of osteoporotic-related fractures in men and women over age 50,” Ms. McChesney said. “This is concerning as many of these AEDs are not only used to manage epilepsy, but are also widely used in older adults for the treatment of neuropathic pain, headaches, and psychiatric conditions, to name a few.”

Ms. McChesney, a nursing student at the University of Calgary, Alta., and colleagues analyzed population-based data from the province of Manitoba for the years 1996–2004.

Individuals were included if they were at least 50 years of age and had continuous health care coverage during the study period. They were excluded if they had taken osteoprotective medications in the year before a fracture or were residents of long-term care facilities.

Fractures were ascertained from diagnostic codes and were limited to vertebral, wrist, and hip fractures that were not related to severe trauma, according to Ms. McChesney.

Using the fracture date as the index date, each older adult with a fracture was matched with three fracture-free older adults by age, sex, ethnicity, and number of comorbidities.

Use of AEDs, defined as dispensation of a prescription to the individual in the past 4 months, was assessed from a drug database containing virtually all pharmacy dispensations for the province.

Analyses were based on 15,792 older adults who had experienced a fracture and 47,289 older adults who had not, Ms. McChesney reported. Overall, 70% were female, 62% were aged 70 years or older, and 67% had three or more comorbidities.

Fractures most commonly occurred in the wrist (52%), followed by the hip (26%) and vertebrae (22%).

After adjustment for social and demographic characteristics, home care, and comorbidities known to affect fracture risk, older adults had elevated odds of fracture if they used carbamazepine (odds ratio, 1.9), clonazepam (1.3), gabapentin (1.6), phenobarbital (2.2), and phenytoin (2.1). In contrast, their odds were not elevated if they used valproic acid.

It remains unknown if osteoprotective agents are beneficial in this context, she acknowledged, and that would be an important focus of additional research.

Ms. McChesney reported that she had no disclosures to make in relation to the study.