Robert Finn

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth that is characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

Complications occurred in only 1% of patients. There were four perforations and four bleeding episodes, which are typical of any endoscopic procedure and not specifically related to CLE. The only CLE-specific complications—five cases of nausea and nine cases of decreased blood pressure—were related to the intravenous fluorescein.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

There were no fluorescein-related complications, but pneumonia developed in one patient who underwent CLE.

“Currently the biopsies go out to the pathologist [and] a week later I have to call the patient, discuss the results, do another invasive procedure, and then do a mucosal resection of the areas of dysplasia,” said Dr. Dunbar of Johns Hopkins University, Baltimore. “One of the great promises of confocal microscopy is that we instantly get a diagnosis.”

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth that is characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

Complications occurred in only 1% of patients. There were four perforations and four bleeding episodes, which are typical of any endoscopic procedure and not specifically related to CLE. The only CLE-specific complications—five cases of nausea and nine cases of decreased blood pressure—were related to the intravenous fluorescein.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

There were no fluorescein-related complications, but pneumonia developed in one patient who underwent CLE.

“Currently the biopsies go out to the pathologist [and] a week later I have to call the patient, discuss the results, do another invasive procedure, and then do a mucosal resection of the areas of dysplasia,” said Dr. Dunbar of Johns Hopkins University, Baltimore. “One of the great promises of confocal microscopy is that we instantly get a diagnosis.”

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth that is characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

Complications occurred in only 1% of patients. There were four perforations and four bleeding episodes, which are typical of any endoscopic procedure and not specifically related to CLE. The only CLE-specific complications—five cases of nausea and nine cases of decreased blood pressure—were related to the intravenous fluorescein.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

There were no fluorescein-related complications, but pneumonia developed in one patient who underwent CLE.

“Currently the biopsies go out to the pathologist [and] a week later I have to call the patient, discuss the results, do another invasive procedure, and then do a mucosal resection of the areas of dysplasia,” said Dr. Dunbar of Johns Hopkins University, Baltimore. “One of the great promises of confocal microscopy is that we instantly get a diagnosis.”

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate, compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

“One of the great promises of confocal microscopy is that we instantly get a diagnosis: 'Aha, here's the area of dysplasia. I'm going to do a mucosal resection now.' And the patient only gets one sedated procedure,” said Dr. Dunbar of Johns Hopkins University, Baltimore.

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

'One of the great promises of confocal microscopy is that we instantly get a diagnosis.' DR. DUNBAR

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate, compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

“One of the great promises of confocal microscopy is that we instantly get a diagnosis: 'Aha, here's the area of dysplasia. I'm going to do a mucosal resection now.' And the patient only gets one sedated procedure,” said Dr. Dunbar of Johns Hopkins University, Baltimore.

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

'One of the great promises of confocal microscopy is that we instantly get a diagnosis.' DR. DUNBAR

SAN DIEGO — Two studies presented at the annual Digestive Disease Week indicate that confocal laser endoscopy increases diagnostic yield and is both accurate and safe.

The studies suggest that one day it may be possible to skip a step in the diagnosis and treatment of Barrett's esophagus, Dr. Kerry B. Dunbar said in a news conference. Dr. Dunbar was the senior author of the randomized study and a coauthor of the retrospective study.

In confocal laser endoscopy (CLE), an endoscope is equipped with a microscope that magnifies living cells close to the surface of the GI tract 1,000 times. When used in conjunction with intravenous contrast agents such as fluorescein, acriflavine, and cresyl violet, the microscope allows endoscopists to visualize the abnormal cell growth characteristic of cancerous lesions.

In one study, investigators retrospectively combined the results of 2,102 CLE examinations on 1,771 patients at three academic medical centers. They found the “optical biopsy” technique to be 91% accurate, compared with standard biopsy. Moreover, the technique changed the initial diagnosis in 32% of the upper GI examinations and 22% of examinations of the lower GI tract.

The other study was a prospective, controlled, crossover trial in which 36 patients underwent both CLE and standard endoscopy (in random order and separated by 2–6 weeks) to identify areas of dysplasia in Barrett's esophagus. The two techniques uncovered about the same number of sites with high-grade dysplasia, but CLE required 60% fewer mucosal biopsies to do so.

Furthermore, 9 of 15 patients (60%) at high risk of high-grade dysplasia and 14 of 21 patients (67%) undergoing surveillance endoscopy following a Barrett's diagnosis required no mucosal biopsies at all during their CLE procedures, because the investigators detected no suspicious sites.

“One of the great promises of confocal microscopy is that we instantly get a diagnosis: 'Aha, here's the area of dysplasia. I'm going to do a mucosal resection now.' And the patient only gets one sedated procedure,” said Dr. Dunbar of Johns Hopkins University, Baltimore.

Dr. Dunbar said she had no relevant conflicts of interest, but disclosed that one of the investigators in the retrospective study received unrestricted research funding from Pentax, which manufactures a CLE system. The randomized study was funded by the National Institutes of Health and by a research award from the American Society of Gastrointestinal Endoscopy.

'One of the great promises of confocal microscopy is that we instantly get a diagnosis.' DR. DUNBAR

HONOLULU — Hypothyroidism has only a minor effect on weight gain, and correcting it does not result in significant weight loss, according to the findings of an observational study.

“[Physicians] have been trained that hypothyroidism causes weight gain and any child who is overweight needs to have hypothyroidism ruled out,” said the study's investigator Dr. Paul Kaplowitz, chief of the division of endocrinology at Children's National Medical Center, Washington, D.C.

“In fact, hypothyroidism causes very minor weight gain and does not cause the kind of obesity that we're seeing so commonly in our young patients. [With] a child who is 20, 30, 50 pounds overweight, hypothyroidism should not be very high on your list,” he said in an interview about the poster, which he presented at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Dr. Kaplowitz and his colleague, Dr. Melissa Crocker, studied 29 moderate to severe hypothyroid and 57 hyperthyroid children referred for an initial evaluation between March 2004 and October 2007. Weight and height measurements were made at diagnosis, at the first follow-up 1–4 months after initiating therapy, and at a second follow-up at about month 6 (hyperthyroid) or month 11 (hypothyroid).

At the first follow-up, the 26 hypothyroid children receiving treatment (mean age 10.7 years) had lost an average of 0.4 kg, exactly the same amount as the 3 uncorrected hypothyroid children. At the second follow-up, the euthyroid children had gained an average of 2.0 kg while the uncorrected children had gained 0.6 kg.

Since some of this weight gain could have been explained by natural or catch-up growth, the investigators looked at the change in the standard deviation of the children's body mass index. This turned out to be -0.2 for the euthyroid children and -0.5 for the uncorrected children, which was not significantly different.

Dr. Kaplowitz said the most interesting observation was that there was no significant difference in the body mass index between the hyperthyroid and hypothyroid patients at diagnosis. “It's variable in both groups. The difference between the two is very small relative to the difference within each group.”

The mean BMI of the 57 hyperthyroid children was 21.1 kg/m

Dr. Kaplowitz said that thyroid testing might be appropriate if the child had additional symptoms beyond weight gain. “The most common symptom of hypothyroidism was feeling fatigued, but feeling colder and more depressed and decreased appetite were also common.”

However, if a patient is losing weight, “think about hyperthyroidism and see if they have any of these suggestive signs: feeling hot, doing poorly in school, enlarged thyroid. Definitely hyperthyroidism should be considered if they're losing weight and have any other symptoms.”

The investigators said that they had no conflicts of interest to declare.

Hypothyroidism causes very minor weight gain and does not cause the kind of obesity so commonly seen in young patients. DR. KAPLOWITZ

HONOLULU — Hypothyroidism has only a minor effect on weight gain, and correcting it does not result in significant weight loss, according to the findings of an observational study.

“[Physicians] have been trained that hypothyroidism causes weight gain and any child who is overweight needs to have hypothyroidism ruled out,” said the study's investigator Dr. Paul Kaplowitz, chief of the division of endocrinology at Children's National Medical Center, Washington, D.C.

“In fact, hypothyroidism causes very minor weight gain and does not cause the kind of obesity that we're seeing so commonly in our young patients. [With] a child who is 20, 30, 50 pounds overweight, hypothyroidism should not be very high on your list,” he said in an interview about the poster, which he presented at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Dr. Kaplowitz and his colleague, Dr. Melissa Crocker, studied 29 moderate to severe hypothyroid and 57 hyperthyroid children referred for an initial evaluation between March 2004 and October 2007. Weight and height measurements were made at diagnosis, at the first follow-up 1–4 months after initiating therapy, and at a second follow-up at about month 6 (hyperthyroid) or month 11 (hypothyroid).

At the first follow-up, the 26 hypothyroid children receiving treatment (mean age 10.7 years) had lost an average of 0.4 kg, exactly the same amount as the 3 uncorrected hypothyroid children. At the second follow-up, the euthyroid children had gained an average of 2.0 kg while the uncorrected children had gained 0.6 kg.

Since some of this weight gain could have been explained by natural or catch-up growth, the investigators looked at the change in the standard deviation of the children's body mass index. This turned out to be -0.2 for the euthyroid children and -0.5 for the uncorrected children, which was not significantly different.

Dr. Kaplowitz said the most interesting observation was that there was no significant difference in the body mass index between the hyperthyroid and hypothyroid patients at diagnosis. “It's variable in both groups. The difference between the two is very small relative to the difference within each group.”

The mean BMI of the 57 hyperthyroid children was 21.1 kg/m

Dr. Kaplowitz said that thyroid testing might be appropriate if the child had additional symptoms beyond weight gain. “The most common symptom of hypothyroidism was feeling fatigued, but feeling colder and more depressed and decreased appetite were also common.”

However, if a patient is losing weight, “think about hyperthyroidism and see if they have any of these suggestive signs: feeling hot, doing poorly in school, enlarged thyroid. Definitely hyperthyroidism should be considered if they're losing weight and have any other symptoms.”

The investigators said that they had no conflicts of interest to declare.

Hypothyroidism causes very minor weight gain and does not cause the kind of obesity so commonly seen in young patients. DR. KAPLOWITZ

HONOLULU — Hypothyroidism has only a minor effect on weight gain, and correcting it does not result in significant weight loss, according to the findings of an observational study.

“[Physicians] have been trained that hypothyroidism causes weight gain and any child who is overweight needs to have hypothyroidism ruled out,” said the study's investigator Dr. Paul Kaplowitz, chief of the division of endocrinology at Children's National Medical Center, Washington, D.C.

“In fact, hypothyroidism causes very minor weight gain and does not cause the kind of obesity that we're seeing so commonly in our young patients. [With] a child who is 20, 30, 50 pounds overweight, hypothyroidism should not be very high on your list,” he said in an interview about the poster, which he presented at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Dr. Kaplowitz and his colleague, Dr. Melissa Crocker, studied 29 moderate to severe hypothyroid and 57 hyperthyroid children referred for an initial evaluation between March 2004 and October 2007. Weight and height measurements were made at diagnosis, at the first follow-up 1–4 months after initiating therapy, and at a second follow-up at about month 6 (hyperthyroid) or month 11 (hypothyroid).

At the first follow-up, the 26 hypothyroid children receiving treatment (mean age 10.7 years) had lost an average of 0.4 kg, exactly the same amount as the 3 uncorrected hypothyroid children. At the second follow-up, the euthyroid children had gained an average of 2.0 kg while the uncorrected children had gained 0.6 kg.

Since some of this weight gain could have been explained by natural or catch-up growth, the investigators looked at the change in the standard deviation of the children's body mass index. This turned out to be -0.2 for the euthyroid children and -0.5 for the uncorrected children, which was not significantly different.

Dr. Kaplowitz said the most interesting observation was that there was no significant difference in the body mass index between the hyperthyroid and hypothyroid patients at diagnosis. “It's variable in both groups. The difference between the two is very small relative to the difference within each group.”

The mean BMI of the 57 hyperthyroid children was 21.1 kg/m

Dr. Kaplowitz said that thyroid testing might be appropriate if the child had additional symptoms beyond weight gain. “The most common symptom of hypothyroidism was feeling fatigued, but feeling colder and more depressed and decreased appetite were also common.”

However, if a patient is losing weight, “think about hyperthyroidism and see if they have any of these suggestive signs: feeling hot, doing poorly in school, enlarged thyroid. Definitely hyperthyroidism should be considered if they're losing weight and have any other symptoms.”

The investigators said that they had no conflicts of interest to declare.

Hypothyroidism causes very minor weight gain and does not cause the kind of obesity so commonly seen in young patients. DR. KAPLOWITZ

SAN FRANCISCO – In psychiatry, the thinking has changed on working with psychotherapists who lack medical degrees, according to Dr. John Q. Young.

Dr. Young, a psychiatrist with the University of California, San Francisco, said knowing how to collaborate with doctorate- or masters-level psychotherapists is an increasingly important skill.

Years ago, not only was the emphasis on treatment by the medical doctor, but the physician often showed undisguised hostility to other clinicians, Dr. Young said at a meeting on depression research and treatment sponsored by the university. Some psychiatrists framed these issues in ethical terms. For example, a survey of psychiatrists in the 1980s showed that fully two-thirds believed that it was unethical to collaborate with non-MD therapists, he said.

More recent models of interactions between psychiatrists and psychotherapists emphasize relationships that are supervisory, consultative, or collaborative.

In a typical collaborative scenario, the psychiatrist manages the patient's medications while the other clinician–a psychologist, a clinical social worker, or a marriage and family therapist–provides psychotherapy.

Other, more complex scenarios also are possible. For example, while the psychiatrist provides pharmacotherapy, one therapist might provide group dialectical-behavior therapy, another therapist might provide individual therapy, a neurologist might treat the patient's complicated migraines, and a primary care physician or specialist might treat the patient's chronic fibromyalgia pain.

Even the typical scenario sets up complicated triangular patterns of transference and countertransference. Still, Dr. Young offered several tips aimed at making such collaborations pleasant and therapeutically fruitful.

Dr. Young recommended establishing a written or oral contract with the patient and the other clinician at the beginning of therapy. At the Langley Porter Psychiatric Hospital and Clinics, where Dr. Young serves as associate director of the adult psychiatry clinic, psychiatrists use a standard form called “Collaborative Treatment Notice to Patients.” This form emphasizes that there is no supervisory relationship between the psychiatrist and the therapist, but that the two will be communicating as necessary about the patient's case.

The notice clarifies that medication-related problems or questions should go to the psychiatrist and that other concerns about treatment should go to the therapist.

One step the psychiatrist can take is to telephone or meet with the psychotherapist early in the patient's treatment, when it's critical to discuss and agree on a diagnosis. In Dr. Young's experience, the psychiatrist gains useful information–and the psychotherapist is pleasantly surprised–if the psychiatrist inquires about the therapist's working diagnosis.

It also is helpful for the psychiatrist and psychotherapist to learn and appreciate each other's focus. “This goes to developing ways of relating beyond our historic tribal conflicts,” Dr. Young said. Furthermore, it is in everyone's best interests for the collaborators to understand each other's approach and training, elucidate belief systems around risk management, and be explicit about goals for psychotherapy and pharmacotherapy.

Agreeing on the type and frequency of routine and emergent communication is an important part of the collaborative process. “Our minimum standard for our clinicians is to call when there's any change in clinical status or treatment and to ask that the other collaborators do the same,” Dr. Young said. “Some of us practice what I call 'turbo-collaboration,' where a psychiatrist tries to call after each visit with a message summarizing what the patient's status was and any change in meds.”

Dr. Young stated that he had no conflicts of interest related to his presentation.

SAN FRANCISCO – In psychiatry, the thinking has changed on working with psychotherapists who lack medical degrees, according to Dr. John Q. Young.

Dr. Young, a psychiatrist with the University of California, San Francisco, said knowing how to collaborate with doctorate- or masters-level psychotherapists is an increasingly important skill.

Years ago, not only was the emphasis on treatment by the medical doctor, but the physician often showed undisguised hostility to other clinicians, Dr. Young said at a meeting on depression research and treatment sponsored by the university. Some psychiatrists framed these issues in ethical terms. For example, a survey of psychiatrists in the 1980s showed that fully two-thirds believed that it was unethical to collaborate with non-MD therapists, he said.

More recent models of interactions between psychiatrists and psychotherapists emphasize relationships that are supervisory, consultative, or collaborative.

In a typical collaborative scenario, the psychiatrist manages the patient's medications while the other clinician–a psychologist, a clinical social worker, or a marriage and family therapist–provides psychotherapy.

Other, more complex scenarios also are possible. For example, while the psychiatrist provides pharmacotherapy, one therapist might provide group dialectical-behavior therapy, another therapist might provide individual therapy, a neurologist might treat the patient's complicated migraines, and a primary care physician or specialist might treat the patient's chronic fibromyalgia pain.

Even the typical scenario sets up complicated triangular patterns of transference and countertransference. Still, Dr. Young offered several tips aimed at making such collaborations pleasant and therapeutically fruitful.

Dr. Young recommended establishing a written or oral contract with the patient and the other clinician at the beginning of therapy. At the Langley Porter Psychiatric Hospital and Clinics, where Dr. Young serves as associate director of the adult psychiatry clinic, psychiatrists use a standard form called “Collaborative Treatment Notice to Patients.” This form emphasizes that there is no supervisory relationship between the psychiatrist and the therapist, but that the two will be communicating as necessary about the patient's case.

The notice clarifies that medication-related problems or questions should go to the psychiatrist and that other concerns about treatment should go to the therapist.

One step the psychiatrist can take is to telephone or meet with the psychotherapist early in the patient's treatment, when it's critical to discuss and agree on a diagnosis. In Dr. Young's experience, the psychiatrist gains useful information–and the psychotherapist is pleasantly surprised–if the psychiatrist inquires about the therapist's working diagnosis.

It also is helpful for the psychiatrist and psychotherapist to learn and appreciate each other's focus. “This goes to developing ways of relating beyond our historic tribal conflicts,” Dr. Young said. Furthermore, it is in everyone's best interests for the collaborators to understand each other's approach and training, elucidate belief systems around risk management, and be explicit about goals for psychotherapy and pharmacotherapy.

Agreeing on the type and frequency of routine and emergent communication is an important part of the collaborative process. “Our minimum standard for our clinicians is to call when there's any change in clinical status or treatment and to ask that the other collaborators do the same,” Dr. Young said. “Some of us practice what I call 'turbo-collaboration,' where a psychiatrist tries to call after each visit with a message summarizing what the patient's status was and any change in meds.”

Dr. Young stated that he had no conflicts of interest related to his presentation.

SAN FRANCISCO – In psychiatry, the thinking has changed on working with psychotherapists who lack medical degrees, according to Dr. John Q. Young.

Dr. Young, a psychiatrist with the University of California, San Francisco, said knowing how to collaborate with doctorate- or masters-level psychotherapists is an increasingly important skill.

Years ago, not only was the emphasis on treatment by the medical doctor, but the physician often showed undisguised hostility to other clinicians, Dr. Young said at a meeting on depression research and treatment sponsored by the university. Some psychiatrists framed these issues in ethical terms. For example, a survey of psychiatrists in the 1980s showed that fully two-thirds believed that it was unethical to collaborate with non-MD therapists, he said.

More recent models of interactions between psychiatrists and psychotherapists emphasize relationships that are supervisory, consultative, or collaborative.

In a typical collaborative scenario, the psychiatrist manages the patient's medications while the other clinician–a psychologist, a clinical social worker, or a marriage and family therapist–provides psychotherapy.

Other, more complex scenarios also are possible. For example, while the psychiatrist provides pharmacotherapy, one therapist might provide group dialectical-behavior therapy, another therapist might provide individual therapy, a neurologist might treat the patient's complicated migraines, and a primary care physician or specialist might treat the patient's chronic fibromyalgia pain.

Even the typical scenario sets up complicated triangular patterns of transference and countertransference. Still, Dr. Young offered several tips aimed at making such collaborations pleasant and therapeutically fruitful.

Dr. Young recommended establishing a written or oral contract with the patient and the other clinician at the beginning of therapy. At the Langley Porter Psychiatric Hospital and Clinics, where Dr. Young serves as associate director of the adult psychiatry clinic, psychiatrists use a standard form called “Collaborative Treatment Notice to Patients.” This form emphasizes that there is no supervisory relationship between the psychiatrist and the therapist, but that the two will be communicating as necessary about the patient's case.

The notice clarifies that medication-related problems or questions should go to the psychiatrist and that other concerns about treatment should go to the therapist.

One step the psychiatrist can take is to telephone or meet with the psychotherapist early in the patient's treatment, when it's critical to discuss and agree on a diagnosis. In Dr. Young's experience, the psychiatrist gains useful information–and the psychotherapist is pleasantly surprised–if the psychiatrist inquires about the therapist's working diagnosis.

It also is helpful for the psychiatrist and psychotherapist to learn and appreciate each other's focus. “This goes to developing ways of relating beyond our historic tribal conflicts,” Dr. Young said. Furthermore, it is in everyone's best interests for the collaborators to understand each other's approach and training, elucidate belief systems around risk management, and be explicit about goals for psychotherapy and pharmacotherapy.

Agreeing on the type and frequency of routine and emergent communication is an important part of the collaborative process. “Our minimum standard for our clinicians is to call when there's any change in clinical status or treatment and to ask that the other collaborators do the same,” Dr. Young said. “Some of us practice what I call 'turbo-collaboration,' where a psychiatrist tries to call after each visit with a message summarizing what the patient's status was and any change in meds.”

Dr. Young stated that he had no conflicts of interest related to his presentation.

HONOLULU – More than 800,000 cases of attention-deficit/hyperactivity disorder in the United States may be linked to childhood exposure to lead and intrauterine exposure to tobacco smoke, Dr. Tanya E. Froehlich said at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Her cross-sectional study used data from a nationally representative sample of children aged 8–15 years, which was part of the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. Data were collected from 2,588 children and their parents.

Dr. Froehlich of Cincinnati Children's Hospital Medical Center was able to determine that 9% of that sample met DSM-IV criteria for ADHD.

In the bivariate analysis, blood lead levels, in utero tobacco smoke, and serum cotinine were all significantly associated with ADHD. However, after controlling for current tobacco exposure, age, sex, race/ethnicity, preschool attendance, maternal age at child's birth, and birth weight in a multivariate analysis, only lead and in utero tobacco smoke remained significantly associated with ADHD.

Children whose mothers reported smoking during pregnancy were 2.4-fold more likely to develop ADHD than were those whose mothers reported not smoking during pregnancy. Compared with children in the first tertile of blood lead level, those in the second tertile were 1.7-fold more likely to develop ADHD. That increased to 2.3-fold for children in the third tertile. All of those results were statistically significant.

Dr. Froehlich was able to determine that 35% of the current prevalent cases of ADHD in the United States could be linked to in utero tobacco exposure or to blood lead levels in the third tertile. This corresponds to 824,000 excess cases of ADHD.

Dr. Froehlich stated that she had no conflicts of interest related to her presentation.

HONOLULU – More than 800,000 cases of attention-deficit/hyperactivity disorder in the United States may be linked to childhood exposure to lead and intrauterine exposure to tobacco smoke, Dr. Tanya E. Froehlich said at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Her cross-sectional study used data from a nationally representative sample of children aged 8–15 years, which was part of the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. Data were collected from 2,588 children and their parents.

Dr. Froehlich of Cincinnati Children's Hospital Medical Center was able to determine that 9% of that sample met DSM-IV criteria for ADHD.

In the bivariate analysis, blood lead levels, in utero tobacco smoke, and serum cotinine were all significantly associated with ADHD. However, after controlling for current tobacco exposure, age, sex, race/ethnicity, preschool attendance, maternal age at child's birth, and birth weight in a multivariate analysis, only lead and in utero tobacco smoke remained significantly associated with ADHD.

Children whose mothers reported smoking during pregnancy were 2.4-fold more likely to develop ADHD than were those whose mothers reported not smoking during pregnancy. Compared with children in the first tertile of blood lead level, those in the second tertile were 1.7-fold more likely to develop ADHD. That increased to 2.3-fold for children in the third tertile. All of those results were statistically significant.

Dr. Froehlich was able to determine that 35% of the current prevalent cases of ADHD in the United States could be linked to in utero tobacco exposure or to blood lead levels in the third tertile. This corresponds to 824,000 excess cases of ADHD.

Dr. Froehlich stated that she had no conflicts of interest related to her presentation.

HONOLULU – More than 800,000 cases of attention-deficit/hyperactivity disorder in the United States may be linked to childhood exposure to lead and intrauterine exposure to tobacco smoke, Dr. Tanya E. Froehlich said at the joint meeting of the Pediatric Academic Societies and the Asian Society for Pediatric Research.

Her cross-sectional study used data from a nationally representative sample of children aged 8–15 years, which was part of the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. Data were collected from 2,588 children and their parents.

Dr. Froehlich of Cincinnati Children's Hospital Medical Center was able to determine that 9% of that sample met DSM-IV criteria for ADHD.

In the bivariate analysis, blood lead levels, in utero tobacco smoke, and serum cotinine were all significantly associated with ADHD. However, after controlling for current tobacco exposure, age, sex, race/ethnicity, preschool attendance, maternal age at child's birth, and birth weight in a multivariate analysis, only lead and in utero tobacco smoke remained significantly associated with ADHD.

Children whose mothers reported smoking during pregnancy were 2.4-fold more likely to develop ADHD than were those whose mothers reported not smoking during pregnancy. Compared with children in the first tertile of blood lead level, those in the second tertile were 1.7-fold more likely to develop ADHD. That increased to 2.3-fold for children in the third tertile. All of those results were statistically significant.

Dr. Froehlich was able to determine that 35% of the current prevalent cases of ADHD in the United States could be linked to in utero tobacco exposure or to blood lead levels in the third tertile. This corresponds to 824,000 excess cases of ADHD.

Dr. Froehlich stated that she had no conflicts of interest related to her presentation.

Patients with both type 2 diabetes and metabolic syndrome have strokes an average of 3.5 years earlier than do those who have type 2 diabetes alone, according to a study.

There were no significant differences between diabetes patients with and without metabolic syndrome in the type of stroke, with lacunar stroke predominating in both groups, wrote Imtiaz M. Shah and colleagues from Ayr (Scotland) Hospital (Diabetes Res. Clin. Prac. 2008;79:e1-e4).

The retrospective study involved 151 patients with metabolic syndrome and type 2 diabetes, and a control group of 92 patients with diabetes alone. All patients had experienced a stroke between September 1996 and August 2004. Patients were considered to have metabolic syndrome if they had two or more of the following additional risk factors: obesity, low HDL cholesterol, elevated triglycerides, or hypertension.

Patients with metabolic syndrome experienced their stroke at an average of 71.7 years of age, compared with 75.2 years among the control group. Other than the defining characteristics of metabolic syndrome, the only other significant difference between the groups was in the proportion taking statins (40% among patients with metabolic syndrome and 24% among the control group).

Lacunar stroke, an indication of small-vessel disease, was responsible for 44% of strokes in both control patients and 44% of strokes in patients with metabolic syndrome. Transient ischemic attacks accounted for 39% of the strokes in control patients and 38% of the patients with metabolic syndrome; cortical strokes accounted for 15% and 13% of the strokes, respectively; and intracerebral hemorrhage accounted for 2% and 5% of the strokes.

The investigators stated that they had no conflicts of interest.

Patients with both type 2 diabetes and metabolic syndrome have strokes an average of 3.5 years earlier than do those who have type 2 diabetes alone, according to a study.

There were no significant differences between diabetes patients with and without metabolic syndrome in the type of stroke, with lacunar stroke predominating in both groups, wrote Imtiaz M. Shah and colleagues from Ayr (Scotland) Hospital (Diabetes Res. Clin. Prac. 2008;79:e1-e4).

The retrospective study involved 151 patients with metabolic syndrome and type 2 diabetes, and a control group of 92 patients with diabetes alone. All patients had experienced a stroke between September 1996 and August 2004. Patients were considered to have metabolic syndrome if they had two or more of the following additional risk factors: obesity, low HDL cholesterol, elevated triglycerides, or hypertension.

Patients with metabolic syndrome experienced their stroke at an average of 71.7 years of age, compared with 75.2 years among the control group. Other than the defining characteristics of metabolic syndrome, the only other significant difference between the groups was in the proportion taking statins (40% among patients with metabolic syndrome and 24% among the control group).

Lacunar stroke, an indication of small-vessel disease, was responsible for 44% of strokes in both control patients and 44% of strokes in patients with metabolic syndrome. Transient ischemic attacks accounted for 39% of the strokes in control patients and 38% of the patients with metabolic syndrome; cortical strokes accounted for 15% and 13% of the strokes, respectively; and intracerebral hemorrhage accounted for 2% and 5% of the strokes.

The investigators stated that they had no conflicts of interest.

Patients with both type 2 diabetes and metabolic syndrome have strokes an average of 3.5 years earlier than do those who have type 2 diabetes alone, according to a study.

There were no significant differences between diabetes patients with and without metabolic syndrome in the type of stroke, with lacunar stroke predominating in both groups, wrote Imtiaz M. Shah and colleagues from Ayr (Scotland) Hospital (Diabetes Res. Clin. Prac. 2008;79:e1-e4).

The retrospective study involved 151 patients with metabolic syndrome and type 2 diabetes, and a control group of 92 patients with diabetes alone. All patients had experienced a stroke between September 1996 and August 2004. Patients were considered to have metabolic syndrome if they had two or more of the following additional risk factors: obesity, low HDL cholesterol, elevated triglycerides, or hypertension.

Patients with metabolic syndrome experienced their stroke at an average of 71.7 years of age, compared with 75.2 years among the control group. Other than the defining characteristics of metabolic syndrome, the only other significant difference between the groups was in the proportion taking statins (40% among patients with metabolic syndrome and 24% among the control group).

Lacunar stroke, an indication of small-vessel disease, was responsible for 44% of strokes in both control patients and 44% of strokes in patients with metabolic syndrome. Transient ischemic attacks accounted for 39% of the strokes in control patients and 38% of the patients with metabolic syndrome; cortical strokes accounted for 15% and 13% of the strokes, respectively; and intracerebral hemorrhage accounted for 2% and 5% of the strokes.

The investigators stated that they had no conflicts of interest.

SAN FRANCISCO — In a randomized trial involving actors portraying patients with major depression, internists and family physicians usually failed to ask these patients about suicidality, even when they correctly made the depression diagnosis, Dr. Mitchell D. Feldman reported at a meeting on depression research sponsored by the University of California in San Francisco.

These primary care physicians were more likely to ask about suicide when the patient made specific requests for medication, compared with patients who made no such request, said Dr. Feldman of the University of California, San Francisco.

Physicians made suicidality inquiries about 46% of the time when depressed “patients” asked about medication, but only 33% of the time when the same actors did not mention medication.

“They knew the patient had depression,” Dr. Feldman said. “They were appropriately prescribing an antidepressant or referring. And yet, they failed to screen for suicidality.” He finds this especially worrisome in light of other studies showing that about half of all people seek some sort of professional help during the month prior to their suicide.

Asking about medication also significantly affected whether the physicians actually issued a prescription. Depressed patients who made a brand-specific request (for Paxil) left the office with a prescription 53% of the time (although not necessarily with that drug), those who made a general request for medication received a prescription 76% of the time, and those who made no request received a prescription 31% of the time.

The study involved 152 primary care physicians in San Francisco; Sacramento, Calif.; and Rochester, N.Y. Two “standardized patients”—one trained to portray major depression of moderate severity and the other to portray adjustment disorder with depressed mood—made unannounced visits to each preselected physician. Investigators informed the physicians that they would be visited by standardized patients (SPs) over the next several months and that each SP would present with a combination of common symptoms. They were told that the purpose of the study was to “assess social influences on practice and the competing demands of primary care.”

Dr. Feldman pointed out that while many primary care physicians find it uncomfortable to inquire about suicidality, it's not that hard to do.

For example, they can ask patients to self-administer the Patient Health Questionnaire-9 (PHQ-9) depression scale, which includes a question about suicidality. Or the physician can simply ask, “This past week, have you had any thoughts that life is not worth living or that you'd be better off dead?” An affirmative answer should trigger further questions to assess the patient's degree of ideation and intent, whether or not he or she has developed a plan, and the availability and lethality of the method chosen.

Many physicians choose to offer a “no suicide contract” to patients exhibiting suicidality. This involves an agreement that the patient will contact the physician or another health care provider if their suicidal feelings or plans escalate.

Dr. Feldman acknowledged that although this approach is based on clinical impressions and not hard evidence, “It's something many of us use, because it just makes us feel better to have this conversation with patients.”

Dr. Feldman and his colleagues have published several papers reporting the results of their SP studies (JAMA 2005;293:1995–2002 and Med. Care 2006;44:1107–13, for example). The PHQ-9 can be downloaded at www.depression-primarycare.org

SAN FRANCISCO — In a randomized trial involving actors portraying patients with major depression, internists and family physicians usually failed to ask these patients about suicidality, even when they correctly made the depression diagnosis, Dr. Mitchell D. Feldman reported at a meeting on depression research sponsored by the University of California in San Francisco.

These primary care physicians were more likely to ask about suicide when the patient made specific requests for medication, compared with patients who made no such request, said Dr. Feldman of the University of California, San Francisco.

Physicians made suicidality inquiries about 46% of the time when depressed “patients” asked about medication, but only 33% of the time when the same actors did not mention medication.

“They knew the patient had depression,” Dr. Feldman said. “They were appropriately prescribing an antidepressant or referring. And yet, they failed to screen for suicidality.” He finds this especially worrisome in light of other studies showing that about half of all people seek some sort of professional help during the month prior to their suicide.

Asking about medication also significantly affected whether the physicians actually issued a prescription. Depressed patients who made a brand-specific request (for Paxil) left the office with a prescription 53% of the time (although not necessarily with that drug), those who made a general request for medication received a prescription 76% of the time, and those who made no request received a prescription 31% of the time.

The study involved 152 primary care physicians in San Francisco; Sacramento, Calif.; and Rochester, N.Y. Two “standardized patients”—one trained to portray major depression of moderate severity and the other to portray adjustment disorder with depressed mood—made unannounced visits to each preselected physician. Investigators informed the physicians that they would be visited by standardized patients (SPs) over the next several months and that each SP would present with a combination of common symptoms. They were told that the purpose of the study was to “assess social influences on practice and the competing demands of primary care.”

Dr. Feldman pointed out that while many primary care physicians find it uncomfortable to inquire about suicidality, it's not that hard to do.

For example, they can ask patients to self-administer the Patient Health Questionnaire-9 (PHQ-9) depression scale, which includes a question about suicidality. Or the physician can simply ask, “This past week, have you had any thoughts that life is not worth living or that you'd be better off dead?” An affirmative answer should trigger further questions to assess the patient's degree of ideation and intent, whether or not he or she has developed a plan, and the availability and lethality of the method chosen.

Many physicians choose to offer a “no suicide contract” to patients exhibiting suicidality. This involves an agreement that the patient will contact the physician or another health care provider if their suicidal feelings or plans escalate.

Dr. Feldman acknowledged that although this approach is based on clinical impressions and not hard evidence, “It's something many of us use, because it just makes us feel better to have this conversation with patients.”

Dr. Feldman and his colleagues have published several papers reporting the results of their SP studies (JAMA 2005;293:1995–2002 and Med. Care 2006;44:1107–13, for example). The PHQ-9 can be downloaded at www.depression-primarycare.org

SAN FRANCISCO — In a randomized trial involving actors portraying patients with major depression, internists and family physicians usually failed to ask these patients about suicidality, even when they correctly made the depression diagnosis, Dr. Mitchell D. Feldman reported at a meeting on depression research sponsored by the University of California in San Francisco.

These primary care physicians were more likely to ask about suicide when the patient made specific requests for medication, compared with patients who made no such request, said Dr. Feldman of the University of California, San Francisco.

Physicians made suicidality inquiries about 46% of the time when depressed “patients” asked about medication, but only 33% of the time when the same actors did not mention medication.

“They knew the patient had depression,” Dr. Feldman said. “They were appropriately prescribing an antidepressant or referring. And yet, they failed to screen for suicidality.” He finds this especially worrisome in light of other studies showing that about half of all people seek some sort of professional help during the month prior to their suicide.

Asking about medication also significantly affected whether the physicians actually issued a prescription. Depressed patients who made a brand-specific request (for Paxil) left the office with a prescription 53% of the time (although not necessarily with that drug), those who made a general request for medication received a prescription 76% of the time, and those who made no request received a prescription 31% of the time.

The study involved 152 primary care physicians in San Francisco; Sacramento, Calif.; and Rochester, N.Y. Two “standardized patients”—one trained to portray major depression of moderate severity and the other to portray adjustment disorder with depressed mood—made unannounced visits to each preselected physician. Investigators informed the physicians that they would be visited by standardized patients (SPs) over the next several months and that each SP would present with a combination of common symptoms. They were told that the purpose of the study was to “assess social influences on practice and the competing demands of primary care.”

Dr. Feldman pointed out that while many primary care physicians find it uncomfortable to inquire about suicidality, it's not that hard to do.

For example, they can ask patients to self-administer the Patient Health Questionnaire-9 (PHQ-9) depression scale, which includes a question about suicidality. Or the physician can simply ask, “This past week, have you had any thoughts that life is not worth living or that you'd be better off dead?” An affirmative answer should trigger further questions to assess the patient's degree of ideation and intent, whether or not he or she has developed a plan, and the availability and lethality of the method chosen.

Many physicians choose to offer a “no suicide contract” to patients exhibiting suicidality. This involves an agreement that the patient will contact the physician or another health care provider if their suicidal feelings or plans escalate.

Dr. Feldman acknowledged that although this approach is based on clinical impressions and not hard evidence, “It's something many of us use, because it just makes us feel better to have this conversation with patients.”

Dr. Feldman and his colleagues have published several papers reporting the results of their SP studies (JAMA 2005;293:1995–2002 and Med. Care 2006;44:1107–13, for example). The PHQ-9 can be downloaded at www.depression-primarycare.org

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

Nearly half of all patients with chronic idiopathic urticaria have Axis I psychiatric diagnoses and 45% have Axis II diagnoses, a new study shows.

Obsessive-compulsive disorder (OCD) and major depression were the most common Axis I diagnoses among 89 consecutive patients with chronic idiopathic urticaria (CIU), and both psychiatric illnesses were significantly more common in the patients than in a control group.

Among the patients, 26% had OCD, compared with 2% of the controls, and 13% had major depression, compared with 3% of the controls, reported Dr. Faruk Uguz and his colleagues at Selcuk University, Konya, Turkey (J. Psychosom. Res. 2008;64:225–9).

Obsessive-compulsive personality disorder and avoidant personality disorder were the most common Axis II diagnoses among the CIU patients, and both were significantly more prevalent in the patients than in the controls. Thirty percent of the patients had obsessive-compulsive personality disorder, compared with 3% of the controls, and 18% of the patients had avoidant personality disorder, compared with 5% of the controls.

Characterized by the rapid appearance of itchy wheals, urticaria is considered chronic when it is recurrent for at least 6 weeks. Few cases have identifiable physical causes, such as infections, reactions to drugs or foods, or vasculitic diseases. But 75% of all cases have no known cause, and these are referred to as chronic idiopathic urticaria.

The study involved 89 consecutive patients with CIU who were seen at an outpatient clinic in Turkey and a control group of 64 hospital employees and their relatives who were matched to the patients' sociodemographic characteristics. The investigators excluded from both groups individuals who were illiterate, and those who had accompanying severe medical illnesses, or had used corticosteroid or psychotropic medications within the prior 4 weeks.

Psychiatrists made Axis I diagnoses using the Structured Clinical Interview for DSM-IV and the Structured Clinical Interview for DSM, Revised Third Edition, Personality Disorders.

In all, 44 of the CIU patients (49%) and 8 of the individuals in the control group (12%) had an Axis I disorder. Forty of the CIU patients (45%) and nine of the controls (14%) had Axis II disorders. Both differences were statistically significant.

The investigators acknowledged that their study could not establish a causal relationship between psychiatric disorders and CIU. Psychiatric disorders could either be a cause or a consequence of CIU.

SAN FRANCISCO – A computer-based intake survey of 422 psychiatric outpatients showed that 27% reported having at least five drinks on a single occasion within the past 30 days, reported Derek D. Satre, Ph.D.

In addition, 28% reported having eight or more drinks at one time during the past year, said Dr. Satre of the department of psychiatry at the University of California, San Francisco and the division of research at Kaiser Permanente, Oakland.

Patients who reported binge drinking had significantly higher scores on the Beck Depression Inventory than did those who did not (26.1 versus 20.6). Men were significantly more likely to report binge drinking than were women, by 32% to 22%, Dr. Satre said.

The findings, reported at a meeting on depression research and treatment sponsored by the university, were part of a broader-based study of substance use among individuals seeking outpatient psychiatric care at the university's Langley Porter Psychiatric Institute. The results of the larger study were published in April (Psychiatr. Serv. 2008;59:441–4).

All 422 of the patients in the smaller study completed the computer-based intake survey on their medical, psychiatric, and substance-use history. Studies show that “people are more willing to divulge drug use and other sensitive information to a computer than to a human being,” he said.

To further increase the possibility of getting honest responses, the intake survey first asked whether the patient had ever in his or her life used a certain substance, and only later asked about use within the past year or month. By asking the less sensitive question about lifetime use first, “We tried not to train them to say no,” Dr. Satre said.

Of the patients, 69.2% were women, 30.3% were men, and 0.5% were transgender individuals. The investigators found statistically significant gender differences in several measures of substance use. For example, 84% of men versus 74% of women reported drinking alcohol, and 9% of men versus 5% of women reported using amphetamines during the past year.

Tobacco, marijuana, and sedatives “other than prescribed” followed alcohol in terms of frequency of use.

Dr. Satre disclosed that he had no financial interests, arrangements, or affiliations with any commercial companies related to his presentation.

SAN FRANCISCO – A computer-based intake survey of 422 psychiatric outpatients showed that 27% reported having at least five drinks on a single occasion within the past 30 days, reported Derek D. Satre, Ph.D.

In addition, 28% reported having eight or more drinks at one time during the past year, said Dr. Satre of the department of psychiatry at the University of California, San Francisco and the division of research at Kaiser Permanente, Oakland.

Patients who reported binge drinking had significantly higher scores on the Beck Depression Inventory than did those who did not (26.1 versus 20.6). Men were significantly more likely to report binge drinking than were women, by 32% to 22%, Dr. Satre said.

The findings, reported at a meeting on depression research and treatment sponsored by the university, were part of a broader-based study of substance use among individuals seeking outpatient psychiatric care at the university's Langley Porter Psychiatric Institute. The results of the larger study were published in April (Psychiatr. Serv. 2008;59:441–4).

All 422 of the patients in the smaller study completed the computer-based intake survey on their medical, psychiatric, and substance-use history. Studies show that “people are more willing to divulge drug use and other sensitive information to a computer than to a human being,” he said.

To further increase the possibility of getting honest responses, the intake survey first asked whether the patient had ever in his or her life used a certain substance, and only later asked about use within the past year or month. By asking the less sensitive question about lifetime use first, “We tried not to train them to say no,” Dr. Satre said.

Of the patients, 69.2% were women, 30.3% were men, and 0.5% were transgender individuals. The investigators found statistically significant gender differences in several measures of substance use. For example, 84% of men versus 74% of women reported drinking alcohol, and 9% of men versus 5% of women reported using amphetamines during the past year.

Tobacco, marijuana, and sedatives “other than prescribed” followed alcohol in terms of frequency of use.

Dr. Satre disclosed that he had no financial interests, arrangements, or affiliations with any commercial companies related to his presentation.

SAN FRANCISCO – A computer-based intake survey of 422 psychiatric outpatients showed that 27% reported having at least five drinks on a single occasion within the past 30 days, reported Derek D. Satre, Ph.D.

In addition, 28% reported having eight or more drinks at one time during the past year, said Dr. Satre of the department of psychiatry at the University of California, San Francisco and the division of research at Kaiser Permanente, Oakland.

Patients who reported binge drinking had significantly higher scores on the Beck Depression Inventory than did those who did not (26.1 versus 20.6). Men were significantly more likely to report binge drinking than were women, by 32% to 22%, Dr. Satre said.

The findings, reported at a meeting on depression research and treatment sponsored by the university, were part of a broader-based study of substance use among individuals seeking outpatient psychiatric care at the university's Langley Porter Psychiatric Institute. The results of the larger study were published in April (Psychiatr. Serv. 2008;59:441–4).

All 422 of the patients in the smaller study completed the computer-based intake survey on their medical, psychiatric, and substance-use history. Studies show that “people are more willing to divulge drug use and other sensitive information to a computer than to a human being,” he said.

To further increase the possibility of getting honest responses, the intake survey first asked whether the patient had ever in his or her life used a certain substance, and only later asked about use within the past year or month. By asking the less sensitive question about lifetime use first, “We tried not to train them to say no,” Dr. Satre said.

Of the patients, 69.2% were women, 30.3% were men, and 0.5% were transgender individuals. The investigators found statistically significant gender differences in several measures of substance use. For example, 84% of men versus 74% of women reported drinking alcohol, and 9% of men versus 5% of women reported using amphetamines during the past year.

Tobacco, marijuana, and sedatives “other than prescribed” followed alcohol in terms of frequency of use.

Dr. Satre disclosed that he had no financial interests, arrangements, or affiliations with any commercial companies related to his presentation.

HUNTINGTON BEACH, CALIF. — It's better to perform a cholecystectomy in a patient with biliary pancreatitis during the patient's first hospital admission than to wait several weeks, according to a study presented by Dr. Kaori Ito at the Academic Surgical Congress.

Current guidelines suggest that it may be acceptable to discharge the patient after resolution of the pancreatitis and then wait 2–4 weeks to perform the operation (Gut 2005;54:1–9; Gastroenterology 2007;132:2019–21). But in a retrospective study, Dr. Ito of Harvard Medical School, Boston, and her colleagues found that delays in cholecystectomy were associated with a high incidence of gallstone-related events, a longer overall length of stay, and worse postoperative outcomes.

Furthermore, performing endoscopic sphincterotomy does not eliminate the risk of recurrent pancreatitis or other gallstone-related events, Dr. Ito said.

The study included 281 patients with biliary pancreatitis; those with necrotizing pancreatitis were excluded. Of the study patients, 162 (group A) underwent cholecystectomy during their initial admission and the other 119 (group B) underwent cholecystectomy on a subsequent admission. The two groups were similar in terms of demographics, comorbidities, and the severity of their pancreatitis. However, a significantly larger proportion of the patients in group A were female (72% vs. 61%).

In group B, during the interval between discharge and cholecystectomy, 39 of the patients (33%) experienced a gallstone-related event. In addition, 16 of those 39 patients had recurrent pancreatitis. Overall, 50% of the patients experiencing recurrent pancreatitis did so within 4 weeks of their initial discharge.

Group A and group B differed significantly on total length of hospital stay: 5 days on average for group A and 7 days for group B (including both hospital admissions). Patients in group A also fared better than those in group B in terms of postoperative recurrence of biliary pancreatitis (3% vs. 10%) and reoperation (0% vs. 3%). There were no statistically significant differences between the groups in readmission after the operation or in perioperative morbidity, and no patients in either group died during the perioperative period.

Endoscopic sphincterotomies were performed in 42 (35%) of the group B patients during the initial hospital admission. The total proportion of gallstone-related events did not differ between the patients who underwent a sphincterotomy and those who did not.

A greater proportion of patients who underwent sphincterotomies experienced acute cholecystitis (12% vs. 1%), but 18% of patients who did not receive a sphincterotomy had recurrent pancreatitis, vs. 5% of those who did. These two differences were statistically significant.

During the question and answer period after the presentation, one physician asked whether there could have been selection bias in this retrospective study. He suggested that there may have been some unknown but systematic difference between the patients who received a cholecystectomy during their initial admission and those who waited. Dr. Ito acknowledged that she could not exclude this possibility.

Dr. Ito stated that she had no relevant financial relationships associated with her presentation.

ELSEVIER GLOBAL MEDICAL NEWS

HUNTINGTON BEACH, CALIF. — It's better to perform a cholecystectomy in a patient with biliary pancreatitis during the patient's first hospital admission than to wait several weeks, according to a study presented by Dr. Kaori Ito at the Academic Surgical Congress.

Current guidelines suggest that it may be acceptable to discharge the patient after resolution of the pancreatitis and then wait 2–4 weeks to perform the operation (Gut 2005;54:1–9; Gastroenterology 2007;132:2019–21). But in a retrospective study, Dr. Ito of Harvard Medical School, Boston, and her colleagues found that delays in cholecystectomy were associated with a high incidence of gallstone-related events, a longer overall length of stay, and worse postoperative outcomes.

Furthermore, performing endoscopic sphincterotomy does not eliminate the risk of recurrent pancreatitis or other gallstone-related events, Dr. Ito said.

The study included 281 patients with biliary pancreatitis; those with necrotizing pancreatitis were excluded. Of the study patients, 162 (group A) underwent cholecystectomy during their initial admission and the other 119 (group B) underwent cholecystectomy on a subsequent admission. The two groups were similar in terms of demographics, comorbidities, and the severity of their pancreatitis. However, a significantly larger proportion of the patients in group A were female (72% vs. 61%).

In group B, during the interval between discharge and cholecystectomy, 39 of the patients (33%) experienced a gallstone-related event. In addition, 16 of those 39 patients had recurrent pancreatitis. Overall, 50% of the patients experiencing recurrent pancreatitis did so within 4 weeks of their initial discharge.

Group A and group B differed significantly on total length of hospital stay: 5 days on average for group A and 7 days for group B (including both hospital admissions). Patients in group A also fared better than those in group B in terms of postoperative recurrence of biliary pancreatitis (3% vs. 10%) and reoperation (0% vs. 3%). There were no statistically significant differences between the groups in readmission after the operation or in perioperative morbidity, and no patients in either group died during the perioperative period.

Endoscopic sphincterotomies were performed in 42 (35%) of the group B patients during the initial hospital admission. The total proportion of gallstone-related events did not differ between the patients who underwent a sphincterotomy and those who did not.

A greater proportion of patients who underwent sphincterotomies experienced acute cholecystitis (12% vs. 1%), but 18% of patients who did not receive a sphincterotomy had recurrent pancreatitis, vs. 5% of those who did. These two differences were statistically significant.

During the question and answer period after the presentation, one physician asked whether there could have been selection bias in this retrospective study. He suggested that there may have been some unknown but systematic difference between the patients who received a cholecystectomy during their initial admission and those who waited. Dr. Ito acknowledged that she could not exclude this possibility.

Dr. Ito stated that she had no relevant financial relationships associated with her presentation.

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HUNTINGTON BEACH, CALIF. — It's better to perform a cholecystectomy in a patient with biliary pancreatitis during the patient's first hospital admission than to wait several weeks, according to a study presented by Dr. Kaori Ito at the Academic Surgical Congress.

Current guidelines suggest that it may be acceptable to discharge the patient after resolution of the pancreatitis and then wait 2–4 weeks to perform the operation (Gut 2005;54:1–9; Gastroenterology 2007;132:2019–21). But in a retrospective study, Dr. Ito of Harvard Medical School, Boston, and her colleagues found that delays in cholecystectomy were associated with a high incidence of gallstone-related events, a longer overall length of stay, and worse postoperative outcomes.

Furthermore, performing endoscopic sphincterotomy does not eliminate the risk of recurrent pancreatitis or other gallstone-related events, Dr. Ito said.

The study included 281 patients with biliary pancreatitis; those with necrotizing pancreatitis were excluded. Of the study patients, 162 (group A) underwent cholecystectomy during their initial admission and the other 119 (group B) underwent cholecystectomy on a subsequent admission. The two groups were similar in terms of demographics, comorbidities, and the severity of their pancreatitis. However, a significantly larger proportion of the patients in group A were female (72% vs. 61%).

In group B, during the interval between discharge and cholecystectomy, 39 of the patients (33%) experienced a gallstone-related event. In addition, 16 of those 39 patients had recurrent pancreatitis. Overall, 50% of the patients experiencing recurrent pancreatitis did so within 4 weeks of their initial discharge.

Group A and group B differed significantly on total length of hospital stay: 5 days on average for group A and 7 days for group B (including both hospital admissions). Patients in group A also fared better than those in group B in terms of postoperative recurrence of biliary pancreatitis (3% vs. 10%) and reoperation (0% vs. 3%). There were no statistically significant differences between the groups in readmission after the operation or in perioperative morbidity, and no patients in either group died during the perioperative period.

Endoscopic sphincterotomies were performed in 42 (35%) of the group B patients during the initial hospital admission. The total proportion of gallstone-related events did not differ between the patients who underwent a sphincterotomy and those who did not.

A greater proportion of patients who underwent sphincterotomies experienced acute cholecystitis (12% vs. 1%), but 18% of patients who did not receive a sphincterotomy had recurrent pancreatitis, vs. 5% of those who did. These two differences were statistically significant.

During the question and answer period after the presentation, one physician asked whether there could have been selection bias in this retrospective study. He suggested that there may have been some unknown but systematic difference between the patients who received a cholecystectomy during their initial admission and those who waited. Dr. Ito acknowledged that she could not exclude this possibility.

Dr. Ito stated that she had no relevant financial relationships associated with her presentation.

ELSEVIER GLOBAL MEDICAL NEWS