Kate Johnson

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers have found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population,” lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said in an interview. “This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection.”

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family members or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said.

“We have some concern about family members and maternal transmission to neonates, and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to—including health care workers.”

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

“The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection,” she explained. No other risk factors for infection—including ethnicity, sex, method of delivery, gestational age, or length of stay—could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included eight blood stream infections, six skin and soft tissue infections, and two ventilator-associated pneumonia cases.

One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. “This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community acquired.”

Dr. Lazenby said decolonization is not currently attempted in neonates. “No one has looked at the effect of topical decolonization, and we do try to be as minimally invasive as possible with neonates in the NICU.”

The current management of colonized infants is isolation and contact precautions to prevent spreading the infection to other babies, she said.

Disclosures: None was reported.

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers have found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population,” lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said in an interview. “This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection.”

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family members or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said.

“We have some concern about family members and maternal transmission to neonates, and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to—including health care workers.”

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

“The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection,” she explained. No other risk factors for infection—including ethnicity, sex, method of delivery, gestational age, or length of stay—could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included eight blood stream infections, six skin and soft tissue infections, and two ventilator-associated pneumonia cases.

One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. “This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community acquired.”

Dr. Lazenby said decolonization is not currently attempted in neonates. “No one has looked at the effect of topical decolonization, and we do try to be as minimally invasive as possible with neonates in the NICU.”

The current management of colonized infants is isolation and contact precautions to prevent spreading the infection to other babies, she said.

Disclosures: None was reported.

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers have found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population,” lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said in an interview. “This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection.”

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family members or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said.

“We have some concern about family members and maternal transmission to neonates, and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to—including health care workers.”

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

“The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection,” she explained. No other risk factors for infection—including ethnicity, sex, method of delivery, gestational age, or length of stay—could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included eight blood stream infections, six skin and soft tissue infections, and two ventilator-associated pneumonia cases.

One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. “This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community acquired.”

Dr. Lazenby said decolonization is not currently attempted in neonates. “No one has looked at the effect of topical decolonization, and we do try to be as minimally invasive as possible with neonates in the NICU.”

The current management of colonized infants is isolation and contact precautions to prevent spreading the infection to other babies, she said.

Disclosures: None was reported.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence—which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31).

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996-1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14).

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, sexual dysfunction, and sleep dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients, because “research is not currently available to support or refute their use specifically in PD patients,” Dr. Zesiewicz said.

However, the new guidelines provide evidence-based recommendations for treating four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, and REM sleep behavior disorder; fatigue; and anxiety.

After conducting a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction (ED) in Parkinson's disease, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.”

Sexual dysfunction is common in both men and women with PD, they wrote. “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

Regarding PD-related sleep dysfunction, the authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, the authors recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests.”

In addition, they said, levodopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warned. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, who is a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim Inc. and Teva Pharmaceutical Industries Ltd.

She also reported that she had received research support from various pharmaceutical companies.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence—which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31).

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996-1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14).

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, sexual dysfunction, and sleep dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients, because “research is not currently available to support or refute their use specifically in PD patients,” Dr. Zesiewicz said.

However, the new guidelines provide evidence-based recommendations for treating four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, and REM sleep behavior disorder; fatigue; and anxiety.

After conducting a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction (ED) in Parkinson's disease, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.”

Sexual dysfunction is common in both men and women with PD, they wrote. “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

Regarding PD-related sleep dysfunction, the authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, the authors recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests.”

In addition, they said, levodopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warned. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, who is a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim Inc. and Teva Pharmaceutical Industries Ltd.

She also reported that she had received research support from various pharmaceutical companies.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence—which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31).

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996-1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14).

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, sexual dysfunction, and sleep dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients, because “research is not currently available to support or refute their use specifically in PD patients,” Dr. Zesiewicz said.

However, the new guidelines provide evidence-based recommendations for treating four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, and REM sleep behavior disorder; fatigue; and anxiety.

After conducting a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction (ED) in Parkinson's disease, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.”

Sexual dysfunction is common in both men and women with PD, they wrote. “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

Regarding PD-related sleep dysfunction, the authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, the authors recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests.”

In addition, they said, levodopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warned. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, who is a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim Inc. and Teva Pharmaceutical Industries Ltd.

She also reported that she had received research support from various pharmaceutical companies.

QUEBEC CITY — Levels of von Willebrand's factor antigen have the potential to provide a sensitive, noninvasive way to monitor disease activity in children with vasculitis involving the central nervous system, Dr. Tania Cellucci and colleagues reported at the annual meeting of the Canadian Rheumatology Association.

Knowing that CNS vasculitis is an autoimmune condition that affects the blood vessel walls, Dr. Cellucci and her colleagues at Toronto's Hospital for Sick Children reasoned that it might impact the release of von Willebrand's factor (vWF) antigen. So they set out to explore vWF levels in 31 consecutive pediatric CNS vasculitis patients from diagnosis through 24 months of follow-up.

The single-center cohort study ran between June 1989 and October 2008. The median age of the patients at diagnosis was 9 years, and 52% were female.

Demographic, clinical, laboratory, imaging, and histologic data were examined at diagnosis and at regular intervals throughout follow-up. Disease activity was measured at diagnosis and every 3 months thereafter using the physician global assessment visual analog scale, and levels of vWF were also measured at these intervals.

Only 10% of the cohort had secondary CNS vasculitis, whereas the remainder had childhood primary angiitis of the CNS (cPACNS), the researchers reported in their poster. More than half of the cohort (58%) had angiography-negative cPACNS, indicating small-vessel disease, whereas 32% had angiography-positive (large-vessel) cPACNS, which was divided evenly between the progressive and nonprogressive form.

As expected, abnormal levels of C-reactive protein (greater than 8 mg/L) and erythrocyte sedimentation rate (greater than 10 mm/h) were not consistent across the cohort at diagnosis, occurring in 20% and 55%, respectively. Leukocytosis (WBC greater than 10 × 109/L) was present in 52%. Opening pressure on lumbar puncture (greater than 20 cm H₂O) was increased in 62%, and elevated cerebrospinal fluid protein (greater than 0.4 g/L) and cerebrospinal fluid leukocytosis (greater than 5 × 106/L) were present in 54% and 72%, respectively. Abnormal magnetic resonance imaging was the most consistent finding, occurring in 94% of the cohort, with vasculitis on brain biopsy present in 71% and abnormal CNS angiogram present in 42%, they reported.

Disease activity decreased significantly and consistently from diagnosis and treatment initiation throughout the course of the study (P less than .0001), reported the researchers, although patients with angiography-negative cPACNS had consistently higher disease activity over time.

At diagnosis, the mean physician global assessment score for all patients with cPACNS was 5.7 for those with angiography-negative disease, and 6.5 for those with positive angiography. By 6 months, the mean scores for the angiography-positive patients had dropped to 1.2, whereas the mean angiography-negative score was 3.3. At 12 months, the mean score for the angiography-negative group was 1.6 vs. 0.9 for the angiography-positive group. Finally, at 24 months, the mean score for the negative group was 2.1, and 0.03 for the positive group.

Mirroring disease activity scores, levels of vWF also decreased over time in all patients (P = .0084) and mirrored disease activity scores, although they were significantly different between subtypes of cPACNS (P = .0028), reported Dr. Cellucci. The study demonstrates that vWF is a sensitive measure of disease activity, she said.

In the example of a stable patient who suddenly develops headaches or other symptoms, “a vWF level could help us figure out whether these new symptoms are due to active disease,” said Dr. Cellucci, who is a fellow in pediatric rheumatology at the University of Toronto. “If vWF is now elevated—and the patient had a high vWF at diagnosis—then this is consistent with a disease flare and we would not need to repeat the invasive tests. If it is normal, then this suggests the new symptoms are not due to disease flare,” she said. She did not define what an abnormal vWF might be, explaining that “all lab reports state the normal ranges for their lab and so the physician will be able to determine whether the level is abnormal or not.”

Dr. Cellucci added that an elevated vWF level can also assist in the diagnosis of pediatric CNS vasculitis, but is not specific enough in isolation. Symptomatic patients would still need invasive diagnostic tests, but an elevated vWF would be consistent with CNS vasculitis, thus guiding the clinician in ordering the work-up, she said.

Disclosures: Dr. Cellucci had no conflicts of interest to report.

Hyperintensity (arrow) in a teen with CNS angiitis is shown on FLAIR image.

Source © 2009 Elsevier Inc.

QUEBEC CITY — Levels of von Willebrand's factor antigen have the potential to provide a sensitive, noninvasive way to monitor disease activity in children with vasculitis involving the central nervous system, Dr. Tania Cellucci and colleagues reported at the annual meeting of the Canadian Rheumatology Association.

Knowing that CNS vasculitis is an autoimmune condition that affects the blood vessel walls, Dr. Cellucci and her colleagues at Toronto's Hospital for Sick Children reasoned that it might impact the release of von Willebrand's factor (vWF) antigen. So they set out to explore vWF levels in 31 consecutive pediatric CNS vasculitis patients from diagnosis through 24 months of follow-up.

The single-center cohort study ran between June 1989 and October 2008. The median age of the patients at diagnosis was 9 years, and 52% were female.

Demographic, clinical, laboratory, imaging, and histologic data were examined at diagnosis and at regular intervals throughout follow-up. Disease activity was measured at diagnosis and every 3 months thereafter using the physician global assessment visual analog scale, and levels of vWF were also measured at these intervals.

Only 10% of the cohort had secondary CNS vasculitis, whereas the remainder had childhood primary angiitis of the CNS (cPACNS), the researchers reported in their poster. More than half of the cohort (58%) had angiography-negative cPACNS, indicating small-vessel disease, whereas 32% had angiography-positive (large-vessel) cPACNS, which was divided evenly between the progressive and nonprogressive form.

As expected, abnormal levels of C-reactive protein (greater than 8 mg/L) and erythrocyte sedimentation rate (greater than 10 mm/h) were not consistent across the cohort at diagnosis, occurring in 20% and 55%, respectively. Leukocytosis (WBC greater than 10 × 109/L) was present in 52%. Opening pressure on lumbar puncture (greater than 20 cm H₂O) was increased in 62%, and elevated cerebrospinal fluid protein (greater than 0.4 g/L) and cerebrospinal fluid leukocytosis (greater than 5 × 106/L) were present in 54% and 72%, respectively. Abnormal magnetic resonance imaging was the most consistent finding, occurring in 94% of the cohort, with vasculitis on brain biopsy present in 71% and abnormal CNS angiogram present in 42%, they reported.

Disease activity decreased significantly and consistently from diagnosis and treatment initiation throughout the course of the study (P less than .0001), reported the researchers, although patients with angiography-negative cPACNS had consistently higher disease activity over time.

At diagnosis, the mean physician global assessment score for all patients with cPACNS was 5.7 for those with angiography-negative disease, and 6.5 for those with positive angiography. By 6 months, the mean scores for the angiography-positive patients had dropped to 1.2, whereas the mean angiography-negative score was 3.3. At 12 months, the mean score for the angiography-negative group was 1.6 vs. 0.9 for the angiography-positive group. Finally, at 24 months, the mean score for the negative group was 2.1, and 0.03 for the positive group.

Mirroring disease activity scores, levels of vWF also decreased over time in all patients (P = .0084) and mirrored disease activity scores, although they were significantly different between subtypes of cPACNS (P = .0028), reported Dr. Cellucci. The study demonstrates that vWF is a sensitive measure of disease activity, she said.

In the example of a stable patient who suddenly develops headaches or other symptoms, “a vWF level could help us figure out whether these new symptoms are due to active disease,” said Dr. Cellucci, who is a fellow in pediatric rheumatology at the University of Toronto. “If vWF is now elevated—and the patient had a high vWF at diagnosis—then this is consistent with a disease flare and we would not need to repeat the invasive tests. If it is normal, then this suggests the new symptoms are not due to disease flare,” she said. She did not define what an abnormal vWF might be, explaining that “all lab reports state the normal ranges for their lab and so the physician will be able to determine whether the level is abnormal or not.”

Dr. Cellucci added that an elevated vWF level can also assist in the diagnosis of pediatric CNS vasculitis, but is not specific enough in isolation. Symptomatic patients would still need invasive diagnostic tests, but an elevated vWF would be consistent with CNS vasculitis, thus guiding the clinician in ordering the work-up, she said.

Disclosures: Dr. Cellucci had no conflicts of interest to report.

Hyperintensity (arrow) in a teen with CNS angiitis is shown on FLAIR image.

Source © 2009 Elsevier Inc.

QUEBEC CITY — Levels of von Willebrand's factor antigen have the potential to provide a sensitive, noninvasive way to monitor disease activity in children with vasculitis involving the central nervous system, Dr. Tania Cellucci and colleagues reported at the annual meeting of the Canadian Rheumatology Association.

Knowing that CNS vasculitis is an autoimmune condition that affects the blood vessel walls, Dr. Cellucci and her colleagues at Toronto's Hospital for Sick Children reasoned that it might impact the release of von Willebrand's factor (vWF) antigen. So they set out to explore vWF levels in 31 consecutive pediatric CNS vasculitis patients from diagnosis through 24 months of follow-up.

The single-center cohort study ran between June 1989 and October 2008. The median age of the patients at diagnosis was 9 years, and 52% were female.

Demographic, clinical, laboratory, imaging, and histologic data were examined at diagnosis and at regular intervals throughout follow-up. Disease activity was measured at diagnosis and every 3 months thereafter using the physician global assessment visual analog scale, and levels of vWF were also measured at these intervals.

Only 10% of the cohort had secondary CNS vasculitis, whereas the remainder had childhood primary angiitis of the CNS (cPACNS), the researchers reported in their poster. More than half of the cohort (58%) had angiography-negative cPACNS, indicating small-vessel disease, whereas 32% had angiography-positive (large-vessel) cPACNS, which was divided evenly between the progressive and nonprogressive form.

As expected, abnormal levels of C-reactive protein (greater than 8 mg/L) and erythrocyte sedimentation rate (greater than 10 mm/h) were not consistent across the cohort at diagnosis, occurring in 20% and 55%, respectively. Leukocytosis (WBC greater than 10 × 109/L) was present in 52%. Opening pressure on lumbar puncture (greater than 20 cm H₂O) was increased in 62%, and elevated cerebrospinal fluid protein (greater than 0.4 g/L) and cerebrospinal fluid leukocytosis (greater than 5 × 106/L) were present in 54% and 72%, respectively. Abnormal magnetic resonance imaging was the most consistent finding, occurring in 94% of the cohort, with vasculitis on brain biopsy present in 71% and abnormal CNS angiogram present in 42%, they reported.

Disease activity decreased significantly and consistently from diagnosis and treatment initiation throughout the course of the study (P less than .0001), reported the researchers, although patients with angiography-negative cPACNS had consistently higher disease activity over time.

At diagnosis, the mean physician global assessment score for all patients with cPACNS was 5.7 for those with angiography-negative disease, and 6.5 for those with positive angiography. By 6 months, the mean scores for the angiography-positive patients had dropped to 1.2, whereas the mean angiography-negative score was 3.3. At 12 months, the mean score for the angiography-negative group was 1.6 vs. 0.9 for the angiography-positive group. Finally, at 24 months, the mean score for the negative group was 2.1, and 0.03 for the positive group.

Mirroring disease activity scores, levels of vWF also decreased over time in all patients (P = .0084) and mirrored disease activity scores, although they were significantly different between subtypes of cPACNS (P = .0028), reported Dr. Cellucci. The study demonstrates that vWF is a sensitive measure of disease activity, she said.

In the example of a stable patient who suddenly develops headaches or other symptoms, “a vWF level could help us figure out whether these new symptoms are due to active disease,” said Dr. Cellucci, who is a fellow in pediatric rheumatology at the University of Toronto. “If vWF is now elevated—and the patient had a high vWF at diagnosis—then this is consistent with a disease flare and we would not need to repeat the invasive tests. If it is normal, then this suggests the new symptoms are not due to disease flare,” she said. She did not define what an abnormal vWF might be, explaining that “all lab reports state the normal ranges for their lab and so the physician will be able to determine whether the level is abnormal or not.”

Dr. Cellucci added that an elevated vWF level can also assist in the diagnosis of pediatric CNS vasculitis, but is not specific enough in isolation. Symptomatic patients would still need invasive diagnostic tests, but an elevated vWF would be consistent with CNS vasculitis, thus guiding the clinician in ordering the work-up, she said.

Disclosures: Dr. Cellucci had no conflicts of interest to report.

Hyperintensity (arrow) in a teen with CNS angiitis is shown on FLAIR image.

Source © 2009 Elsevier Inc.

MONTREAL — Occurance of injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a study presented at the annual meeting of the Canadian Rheumatology Association.

“All we're talking about here is an association; we can't infer causation,” Dr. Dafna Gladman, the study's principal investigator, told Rheumatology News.

Previous, less rigorous studies have suggested the association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto and deputy director of the Centre for Prognosis Studies in the Rheumatic Diseases in that city.

“This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said, explaining that at most, 30% of psoriasis patients go on to develop PsA.

Her study, which was presented as a poster at the meeting, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone, in order to identify risk factors for progression to PsA. Men accounted for a similar percentage of both groups (46% in the PsA group and 44% in the controls).

The mean age of participants in each group was similar (45 years and 48 years, respectively) as was the mean duration of psoriasis (17.5 years and 18.5 years, respectively). The mean duration of PsA was 3 years.

A questionnaire was administered to all patients to assess their environmental exposure over the past 10 years, including occupational trauma, infection, immunization, smoking status and history, and psychological stress.

Univariate and multivariate logistic regression analysis was used to determine the odds ratio of each exposure prior to the diagnosis of PsA. “We actually examined all the patients with psoriasis to make sure they didn't have psoriatic arthritis,” she said.

Univariate analysis revealed that a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an OR of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8.

And the third-highest risk factor was any injury requiring medical attention (OR, 2.43).

Multivariate analysis revealed that injuries requiring medical attention but excluding fracture and motor vehicle accident (OR, 2.3; P = .03), occupations requiring the lifting of heavy loads (OR, 2.7; P = .002), and severe infection requiring hospitalization (OR, 10.6; P = .03) were significantly associated with progression from psoriasis to PsA.

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” said Dr. Gladman.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress; in fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis.”

After the multifactorial analysis, smoking appeared to be associated with decreased risk, she added. Current smoking had an OR of 0.4 (P = .01), and past smoking had an OR of 0.5 (P = .04).

Dr. Gladman said that the findings are too preliminary to inform clinical recommendations at this time, but psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.” She said that the next step should be to look at genetic and environmental factors and see if they are independent or not.

Disclosures: Dr. Gladman declared no conflicts of interest.

Changes in the interphalangeal joints are shown in this x-ray of a patient with PsA in both hands.

Source © 2010 National Medical Slide Bank/Custom Medical Stock Photo, All Rights Reserved

My Take

Now We Need Prospective Trials

The potential impact of trauma on the development of psoriatic arthritis was first proposed over 50 years ago, when the observation of acryo-osteolysis in an injured digit was labeled “deep Koebner's effect.”

Two recent, retrospective, case-control studies analyzed the relationship between trauma and the onset of psoriatic arthritis. Corticosteroid use (in the first report) and immunization, moving house, and injury severe enough to require medical consultation (in the second report) were associated with incident PsA.

Dr. Gladman's study provides additional support for the association between trauma and incident PsA.

In this study, individuals with PsA were matched to psoriasis patients, and investigators found that injury requiring medical attention, heavy lifting, and severe infection were associated with the development of PsA.

Of course, many important questions remain to be addressed.

Could the retrospective designs of these case-control studies be strongly influenced by recall bias? This is possible but unlikely to account for these findings, given that both RA and psoriasis subjects have been used as controls.

A second question centers on the mechanisms that underlie this interesting association.

Two potential explanations have been suggested: the activation of proinflammatory molecules (such as nerve growth factor) that are produced in the psoriatic plaques, or high-level biomechanical stress to the synovial-entheseal complex, which triggers an innate immune response and subsequent inflammation.

Evidence amassed from several different sources supports the concept that trauma may be associated with the onset of PsA.

An adequately powered prospective study of psoriasis patients, with strict case definitions and appropriate control groups, will be required to adequately test the hypothesis and to understand the magnitude of a particular risk factor. Genetic risk factors could also be analyzed in such a study.

In the meantime, we await the details of Dr. Gladman's analysis, and we should make an effort to catalogue the events that are temporally related to the onset of inflammatory arthritis in our patients.

CHRISTOPHER T. RITCHLIN, M.D., is professor of medicine at the University of Rochester (N.Y.). He reports having no relevant conflicts of interest.

MONTREAL — Occurance of injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a study presented at the annual meeting of the Canadian Rheumatology Association.

“All we're talking about here is an association; we can't infer causation,” Dr. Dafna Gladman, the study's principal investigator, told Rheumatology News.

Previous, less rigorous studies have suggested the association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto and deputy director of the Centre for Prognosis Studies in the Rheumatic Diseases in that city.

“This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said, explaining that at most, 30% of psoriasis patients go on to develop PsA.

Her study, which was presented as a poster at the meeting, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone, in order to identify risk factors for progression to PsA. Men accounted for a similar percentage of both groups (46% in the PsA group and 44% in the controls).

The mean age of participants in each group was similar (45 years and 48 years, respectively) as was the mean duration of psoriasis (17.5 years and 18.5 years, respectively). The mean duration of PsA was 3 years.

A questionnaire was administered to all patients to assess their environmental exposure over the past 10 years, including occupational trauma, infection, immunization, smoking status and history, and psychological stress.

Univariate and multivariate logistic regression analysis was used to determine the odds ratio of each exposure prior to the diagnosis of PsA. “We actually examined all the patients with psoriasis to make sure they didn't have psoriatic arthritis,” she said.

Univariate analysis revealed that a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an OR of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8.

And the third-highest risk factor was any injury requiring medical attention (OR, 2.43).

Multivariate analysis revealed that injuries requiring medical attention but excluding fracture and motor vehicle accident (OR, 2.3; P = .03), occupations requiring the lifting of heavy loads (OR, 2.7; P = .002), and severe infection requiring hospitalization (OR, 10.6; P = .03) were significantly associated with progression from psoriasis to PsA.

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” said Dr. Gladman.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress; in fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis.”

After the multifactorial analysis, smoking appeared to be associated with decreased risk, she added. Current smoking had an OR of 0.4 (P = .01), and past smoking had an OR of 0.5 (P = .04).

Dr. Gladman said that the findings are too preliminary to inform clinical recommendations at this time, but psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.” She said that the next step should be to look at genetic and environmental factors and see if they are independent or not.

Disclosures: Dr. Gladman declared no conflicts of interest.

Changes in the interphalangeal joints are shown in this x-ray of a patient with PsA in both hands.

Source © 2010 National Medical Slide Bank/Custom Medical Stock Photo, All Rights Reserved

My Take

Now We Need Prospective Trials

The potential impact of trauma on the development of psoriatic arthritis was first proposed over 50 years ago, when the observation of acryo-osteolysis in an injured digit was labeled “deep Koebner's effect.”

Two recent, retrospective, case-control studies analyzed the relationship between trauma and the onset of psoriatic arthritis. Corticosteroid use (in the first report) and immunization, moving house, and injury severe enough to require medical consultation (in the second report) were associated with incident PsA.

Dr. Gladman's study provides additional support for the association between trauma and incident PsA.

In this study, individuals with PsA were matched to psoriasis patients, and investigators found that injury requiring medical attention, heavy lifting, and severe infection were associated with the development of PsA.

Of course, many important questions remain to be addressed.

Could the retrospective designs of these case-control studies be strongly influenced by recall bias? This is possible but unlikely to account for these findings, given that both RA and psoriasis subjects have been used as controls.

A second question centers on the mechanisms that underlie this interesting association.

Two potential explanations have been suggested: the activation of proinflammatory molecules (such as nerve growth factor) that are produced in the psoriatic plaques, or high-level biomechanical stress to the synovial-entheseal complex, which triggers an innate immune response and subsequent inflammation.

Evidence amassed from several different sources supports the concept that trauma may be associated with the onset of PsA.

An adequately powered prospective study of psoriasis patients, with strict case definitions and appropriate control groups, will be required to adequately test the hypothesis and to understand the magnitude of a particular risk factor. Genetic risk factors could also be analyzed in such a study.

In the meantime, we await the details of Dr. Gladman's analysis, and we should make an effort to catalogue the events that are temporally related to the onset of inflammatory arthritis in our patients.

CHRISTOPHER T. RITCHLIN, M.D., is professor of medicine at the University of Rochester (N.Y.). He reports having no relevant conflicts of interest.

MONTREAL — Occurance of injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a study presented at the annual meeting of the Canadian Rheumatology Association.

“All we're talking about here is an association; we can't infer causation,” Dr. Dafna Gladman, the study's principal investigator, told Rheumatology News.

Previous, less rigorous studies have suggested the association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto and deputy director of the Centre for Prognosis Studies in the Rheumatic Diseases in that city.

“This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said, explaining that at most, 30% of psoriasis patients go on to develop PsA.

Her study, which was presented as a poster at the meeting, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone, in order to identify risk factors for progression to PsA. Men accounted for a similar percentage of both groups (46% in the PsA group and 44% in the controls).

The mean age of participants in each group was similar (45 years and 48 years, respectively) as was the mean duration of psoriasis (17.5 years and 18.5 years, respectively). The mean duration of PsA was 3 years.

A questionnaire was administered to all patients to assess their environmental exposure over the past 10 years, including occupational trauma, infection, immunization, smoking status and history, and psychological stress.

Univariate and multivariate logistic regression analysis was used to determine the odds ratio of each exposure prior to the diagnosis of PsA. “We actually examined all the patients with psoriasis to make sure they didn't have psoriatic arthritis,” she said.

Univariate analysis revealed that a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an OR of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8.

And the third-highest risk factor was any injury requiring medical attention (OR, 2.43).

Multivariate analysis revealed that injuries requiring medical attention but excluding fracture and motor vehicle accident (OR, 2.3; P = .03), occupations requiring the lifting of heavy loads (OR, 2.7; P = .002), and severe infection requiring hospitalization (OR, 10.6; P = .03) were significantly associated with progression from psoriasis to PsA.

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” said Dr. Gladman.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress; in fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis.”

After the multifactorial analysis, smoking appeared to be associated with decreased risk, she added. Current smoking had an OR of 0.4 (P = .01), and past smoking had an OR of 0.5 (P = .04).

Dr. Gladman said that the findings are too preliminary to inform clinical recommendations at this time, but psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.” She said that the next step should be to look at genetic and environmental factors and see if they are independent or not.

Disclosures: Dr. Gladman declared no conflicts of interest.

Changes in the interphalangeal joints are shown in this x-ray of a patient with PsA in both hands.

Source © 2010 National Medical Slide Bank/Custom Medical Stock Photo, All Rights Reserved

My Take

Now We Need Prospective Trials

The potential impact of trauma on the development of psoriatic arthritis was first proposed over 50 years ago, when the observation of acryo-osteolysis in an injured digit was labeled “deep Koebner's effect.”

Two recent, retrospective, case-control studies analyzed the relationship between trauma and the onset of psoriatic arthritis. Corticosteroid use (in the first report) and immunization, moving house, and injury severe enough to require medical consultation (in the second report) were associated with incident PsA.

Dr. Gladman's study provides additional support for the association between trauma and incident PsA.

In this study, individuals with PsA were matched to psoriasis patients, and investigators found that injury requiring medical attention, heavy lifting, and severe infection were associated with the development of PsA.

Of course, many important questions remain to be addressed.

Could the retrospective designs of these case-control studies be strongly influenced by recall bias? This is possible but unlikely to account for these findings, given that both RA and psoriasis subjects have been used as controls.

A second question centers on the mechanisms that underlie this interesting association.

Two potential explanations have been suggested: the activation of proinflammatory molecules (such as nerve growth factor) that are produced in the psoriatic plaques, or high-level biomechanical stress to the synovial-entheseal complex, which triggers an innate immune response and subsequent inflammation.

Evidence amassed from several different sources supports the concept that trauma may be associated with the onset of PsA.

An adequately powered prospective study of psoriasis patients, with strict case definitions and appropriate control groups, will be required to adequately test the hypothesis and to understand the magnitude of a particular risk factor. Genetic risk factors could also be analyzed in such a study.

In the meantime, we await the details of Dr. Gladman's analysis, and we should make an effort to catalogue the events that are temporally related to the onset of inflammatory arthritis in our patients.

CHRISTOPHER T. RITCHLIN, M.D., is professor of medicine at the University of Rochester (N.Y.). He reports having no relevant conflicts of interest.

While infant hearing loss is more frequently screened for and identified in the United States than it was a decade ago, the challenge has now shifted toward the delivery of timely intervention when it's needed, according to a report from the Centers for Disease Control and Prevention.

“Now that [more than] 95% of U.S. infants can be documented as having their hearing screened, remaining challenges include ensuring timely diagnostic evaluation for those who did not pass the screening and enrollment in early intervention for those with diagnosed hearing loss,” wrote M. Gaffney and colleagues from the National Center on Birth Defects and Developmental Disabilities at the CDC.

Early Hearing Detection and Intervention (EHDI) programs established in all states and U.S. territories recommend that infants undergo hearing screening no later than age 1 month, diagnostic and audiologic evaluation no later than age 3 months for infants who do not pass the screening, and enrollment in early intervention no later than age 6 months for infants with diagnosed hearing loss.

But an analysis of CDC and EHDI surveillance data from 1999 through 2007, while showing an increase in screening from 47% to 97%, also found that 46% of infants who did not pass the final or most recent screening in 2007 were either lost to follow-up or lost to documentation (LFU/LTD). When the numbers are evaluated slightly differently, only 61% of infants diagnosed with hearing loss in 2007 were enrolled in early intervention by the age of 6 months (MMWR 2010:59;220-3).

“EHDI programs such as those in Massachusetts and Colorado, which often actively follow up with families and providers and reported LFU/LTD in 2007 of 5.6% and 6.4%, respectively, are good examples for other programs trying to improve overall follow-up rates,” the authors wrote.

The national 2007 LFU/LTD rate of 46% is an improvement over the 2005 rate of 64%, especially considering that more infants were screened and diagnosed with hearing loss in 2007. Indeed, while 52% of infants were screened and 56% of those diagnosed with hearing loss in 2000, 97% were screened and 42% were diagnosed in 2007.

The CDC report outlines its three most significant limitations: The methods and definitions used in data collection differed over the course of the decade, limiting comparability; some states and territories could provide only limited data; and EHDI programs are not designed to detect mild hearing loss below the threshold of 30-40 dB or progressive or late-onset hearing loss.

While infant hearing loss is more frequently screened for and identified in the United States than it was a decade ago, the challenge has now shifted toward the delivery of timely intervention when it's needed, according to a report from the Centers for Disease Control and Prevention.

“Now that [more than] 95% of U.S. infants can be documented as having their hearing screened, remaining challenges include ensuring timely diagnostic evaluation for those who did not pass the screening and enrollment in early intervention for those with diagnosed hearing loss,” wrote M. Gaffney and colleagues from the National Center on Birth Defects and Developmental Disabilities at the CDC.

Early Hearing Detection and Intervention (EHDI) programs established in all states and U.S. territories recommend that infants undergo hearing screening no later than age 1 month, diagnostic and audiologic evaluation no later than age 3 months for infants who do not pass the screening, and enrollment in early intervention no later than age 6 months for infants with diagnosed hearing loss.

But an analysis of CDC and EHDI surveillance data from 1999 through 2007, while showing an increase in screening from 47% to 97%, also found that 46% of infants who did not pass the final or most recent screening in 2007 were either lost to follow-up or lost to documentation (LFU/LTD). When the numbers are evaluated slightly differently, only 61% of infants diagnosed with hearing loss in 2007 were enrolled in early intervention by the age of 6 months (MMWR 2010:59;220-3).

“EHDI programs such as those in Massachusetts and Colorado, which often actively follow up with families and providers and reported LFU/LTD in 2007 of 5.6% and 6.4%, respectively, are good examples for other programs trying to improve overall follow-up rates,” the authors wrote.

The national 2007 LFU/LTD rate of 46% is an improvement over the 2005 rate of 64%, especially considering that more infants were screened and diagnosed with hearing loss in 2007. Indeed, while 52% of infants were screened and 56% of those diagnosed with hearing loss in 2000, 97% were screened and 42% were diagnosed in 2007.

The CDC report outlines its three most significant limitations: The methods and definitions used in data collection differed over the course of the decade, limiting comparability; some states and territories could provide only limited data; and EHDI programs are not designed to detect mild hearing loss below the threshold of 30-40 dB or progressive or late-onset hearing loss.

While infant hearing loss is more frequently screened for and identified in the United States than it was a decade ago, the challenge has now shifted toward the delivery of timely intervention when it's needed, according to a report from the Centers for Disease Control and Prevention.

“Now that [more than] 95% of U.S. infants can be documented as having their hearing screened, remaining challenges include ensuring timely diagnostic evaluation for those who did not pass the screening and enrollment in early intervention for those with diagnosed hearing loss,” wrote M. Gaffney and colleagues from the National Center on Birth Defects and Developmental Disabilities at the CDC.

Early Hearing Detection and Intervention (EHDI) programs established in all states and U.S. territories recommend that infants undergo hearing screening no later than age 1 month, diagnostic and audiologic evaluation no later than age 3 months for infants who do not pass the screening, and enrollment in early intervention no later than age 6 months for infants with diagnosed hearing loss.

But an analysis of CDC and EHDI surveillance data from 1999 through 2007, while showing an increase in screening from 47% to 97%, also found that 46% of infants who did not pass the final or most recent screening in 2007 were either lost to follow-up or lost to documentation (LFU/LTD). When the numbers are evaluated slightly differently, only 61% of infants diagnosed with hearing loss in 2007 were enrolled in early intervention by the age of 6 months (MMWR 2010:59;220-3).

“EHDI programs such as those in Massachusetts and Colorado, which often actively follow up with families and providers and reported LFU/LTD in 2007 of 5.6% and 6.4%, respectively, are good examples for other programs trying to improve overall follow-up rates,” the authors wrote.

The national 2007 LFU/LTD rate of 46% is an improvement over the 2005 rate of 64%, especially considering that more infants were screened and diagnosed with hearing loss in 2007. Indeed, while 52% of infants were screened and 56% of those diagnosed with hearing loss in 2000, 97% were screened and 42% were diagnosed in 2007.

The CDC report outlines its three most significant limitations: The methods and definitions used in data collection differed over the course of the decade, limiting comparability; some states and territories could provide only limited data; and EHDI programs are not designed to detect mild hearing loss below the threshold of 30-40 dB or progressive or late-onset hearing loss.

MONTREAL – Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1–5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, professor of family medicine at the Medical University of South Carolina, Charleston.

Eighty-six percent of the respondents had been using electronic health records (EHRs) for 3 or more years, and 94% had access to the Internet from their clinical workstations.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, only 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as “Do you go on spending sprees? Do you stay up all night? or Do you find yourself having ups and downs, including periods of high irritability, anger or stress?”

As the use of EHRs becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the [EHR] that will give them some quick answers,” he said.

“Many of them are willing to comanage the patient but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications. That was the preference of most of them,” he concluded.

The study was part of a quality improvement project funded by Delaware Valley Outcomes Research and GE Healthcare.

MONTREAL – Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1–5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, professor of family medicine at the Medical University of South Carolina, Charleston.

Eighty-six percent of the respondents had been using electronic health records (EHRs) for 3 or more years, and 94% had access to the Internet from their clinical workstations.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, only 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as “Do you go on spending sprees? Do you stay up all night? or Do you find yourself having ups and downs, including periods of high irritability, anger or stress?”

As the use of EHRs becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the [EHR] that will give them some quick answers,” he said.

“Many of them are willing to comanage the patient but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications. That was the preference of most of them,” he concluded.

The study was part of a quality improvement project funded by Delaware Valley Outcomes Research and GE Healthcare.

MONTREAL – Primary care physicians are not confident when it comes to diagnosing and managing patients with bipolar depression, according to a cross-sectional survey of providers participating in a national electronic health record database.

Among 85 primary care providers in GE Healthcare's Medical Quality Improvement Consortium, self-rated confidence in managing bipolar disorder averaged 1.7 on a scale of 1–5, with 5 being “very confident,” said Dr. Dana King, who presented the findings as a poster at the annual meeting of the North American Primary Care Research Group.

“For other more common disorders such as reflux disease, heart disease, or diabetes, these physicians have more confidence in their ability to sort out complex problems and deal with them. But bipolar disorder is less common and people have less exposure to it during their training,” explained Dr. King, professor of family medicine at the Medical University of South Carolina, Charleston.

Eighty-six percent of the respondents had been using electronic health records (EHRs) for 3 or more years, and 94% had access to the Internet from their clinical workstations.

Although 72% of the respondents said they screened depressed patients for bipolar disorder, only 38% reported frequently using a standard screening tool, the most common being the Mood Disorder Questionnaire.

Informal screening was more common than was the use of standardized tools and consisted of “a few questions about manic activity in patients with depression,” Dr. King said. Such information screening may involve questions such as “Do you go on spending sprees? Do you stay up all night? or Do you find yourself having ups and downs, including periods of high irritability, anger or stress?”

As the use of EHRs becomes more widespread, they may help prompt physicians to screen patients for bipolar disorder by offering pop-up information, he said. This represents an opportunity for quality improvement.

“Physicians seem to like the idea that we could offer them quick medical information via the [EHR] that will give them some quick answers,” he said.

“Many of them are willing to comanage the patient but they first want the diagnosis to be confirmed, typed according to bipolar I or II, with an identification of the phase and recommended medications. That was the preference of most of them,” he concluded.

The study was part of a quality improvement project funded by Delaware Valley Outcomes Research and GE Healthcare.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence–which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31)

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996–1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14)

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, [and] sexual [and sleep] dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients,” she said.

However, the new guidelines provide evidence-based recommendations for the treatment of four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, REM sleep behavior disorder; fatigue; and anxiety.

After a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction in PD, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.” They wrote, “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

The authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, they recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests,” they added.

In addition, they said, levo-dopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warn. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim and Teva Pharmaceutical Industries Ltd. She also reported receiving research support from various pharmaceutical companies.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence–which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31)

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996–1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14)

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, [and] sexual [and sleep] dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients,” she said.

However, the new guidelines provide evidence-based recommendations for the treatment of four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, REM sleep behavior disorder; fatigue; and anxiety.

After a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction in PD, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.” They wrote, “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

The authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, they recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests,” they added.

In addition, they said, levo-dopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warn. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim and Teva Pharmaceutical Industries Ltd. She also reported receiving research support from various pharmaceutical companies.

Nonmotor symptoms of Parkinson's disease remain underdiagnosed despite their widespread occurrence–which is the impetus behind new treatment guidelines from the American Academy of Neurology.

“Nonmotor symptoms are an integral part of this syndrome. These symptoms can be as troublesome as motor symptoms and impact activities of daily living, though they are often underrecognized by health care professionals,” wrote Dr. Theresa A. Zesiewicz, lead author of the guidelines and professor of neurology at the University of South Florida, Tampa (Neurology 2010;74:924-31)

Treatment of depression, dementia, and psychosis in Parkinson's disease (PD) has been addressed in a previous guideline (Neurology 2006;66:996–1002), as has treatment of PD-related sialorrhea with botulinum toxin (Neurology 2008;70:1707-14)

However, there are many other nonmotor symptoms for which there is a paucity of research concerning treatment, wrote Dr. Zesiewicz and her colleagues wrote.

“The disease process of PD certainly contributes to many nonmotor symptoms, including autonomic dysfunction (orthostatic hypotension, gastrointestinal symptoms), depression, [and] sexual [and sleep] dysfunction,” said Dr. Zesiewicz in an interview. “However, medications used to treat PD can contribute to other nonmotor symptoms. For example, the use of some PD medications can contribute to excessive daytime sleepiness, while others can cause insomnia.”

In general, treatment of most nonmotor PD symptoms should mirror the treatments given to non-PD patients,” she said.

However, the new guidelines provide evidence-based recommendations for the treatment of four conditions: erectile dysfunction, constipation, restless legs syndrome, and fatigue.

A wide range of nonmotor symptoms were reviewed for the guidelines, including autonomic dysfunction such as gastrointestinal disorders, orthostatic hypotension, sexual dysfunction, and urinary incontinence; sleep disorders, such as restless legs syndrome, periodic limb movements of sleep, excessive daytime somnolence, insomnia, REM sleep behavior disorder; fatigue; and anxiety.

After a literature search aimed at capturing articles pertaining to these symptoms published between 1966 and 2008, a panel review deemed 46 papers relevant for the development of evidence-based recommendations. They also concluded that there was insufficient evidence to make recommendations regarding the treatment of urinary incontinence, orthostatic hypotension, insomnia, REM sleep behavior disorder, and anxiety.

For the treatment of erectile dysfunction in PD, the authors recommend that sildenafil citrate (50 mg) “is possibly efficacious.” They wrote, “Dysautonomia manifests as erectile dysfunction (ED) but also as reduced genital sensitivity and lubrication and difficulties reaching orgasm.” Only one controlled clinical trial for the treatment of ED was available for review, however.

For constipation, they concluded that isosmotic macrogol (polyethylene glycol) “possibly improves constipation in PD.” Four studies evaluating the efficacy of pharmacologic agents for PD-related constipation were reviewed, and the recommendation is based one class II study.

The authors found sufficient evidence to make treatment recommendations for excessive daytime somnolence (EDS), and restless leg syndrome or periodic limb movements of sleep.

Based on the results of two class I studies, they recommend modafinil to improve patients' perceptions of wakefulness, though “it is ineffective in objectively improving EDS as measured by objective tests,” they added.

In addition, they said, levo-dopa/carbidopa “probably decreases the frequency of spontaneous nighttime leg movements,” based on one class I study and should therefore be considered to treat periodic limb movements of sleep in PD.

And finally, “methylphenidate is possibly useful in treating fatigue in PD,” they concluded, based on one class II study. However, there is potential for abuse, they warn. “Although there is no current evidence to suggest such a risk in PD, patients with PD do have a risk for dopamine dysregulation syndrome and impulse control disorders that share many clinical and functional imaging features with addiction,” they cautioned.

“The same rules for treating PD patients with these medications would apply as when treating any patients, including careful monitoring of drug interactions and taking comorbid conditions into consideration,” Dr. Zesiewicz said.

“Of course, it is important to recognize that the treatments recommended are not the only available treatments,” commented Dr. Ronald B. Postuma, a PD researcher and assistant professor of neurology at the Montreal General Hospital. “The guidelines focus only on therapies that have good randomized controlled trial evidence. All experienced clinicians will recognize several useful treatments that are not in the recommendations because of incomplete evidence,” he said in an interview.

Dr. Zesiewicz reported receiving funding for travel from and serving on speakers bureaus for Boehringer Ingelheim and Teva Pharmaceutical Industries Ltd. She also reported receiving research support from various pharmaceutical companies.

Lip augmentation with autologous sternocleidomastoid muscle and fascia grafts results in enhanced vermilion show and lip projection up to 2 years post procedure, according to a single-center, retrospective study.

“This is another tool in the plastic surgeon’s armamentarium to combat the aging lip, which along with every other technique has some limitations, yet is effective in our practice,” wrote Dr. Anurag Agarwal, of the Aesthetic Surgery Center, Naples, Florida, and colleagues in the March/April issue of Archives of Facial Plastic Surgery.

“Based on the present study, patients who desire subtle, yet long-term lip augmentation can be counseled to expect approximately a 20% to 25% increase in vermilion show and approximately a 1-mm increase in lip projection at 2 years and longer from baseline.”

The study compared baseline and postprocedure photographs of 25 consecutive patients who underwent sternocleidomastoid (SCM) muscle and fascia augmentation of the lips with concurrent cervicofacial rhytidectomy (Arch. Facial Plast. Surg. 2010;12:97-102).

They were compared to similar baseline and postprocedure photographs of 25 control patients who received cervicofacial rhytidectomy alone, with no lip augmentation.

The mean postoperative photograph was taken at 25 months in the SCM group and 21 months in the control group. The ages of the patients were not reported.

For each patient, frontal and right lateral photographs were analyzed. The frontal analysis included measurement of the right and left, upper and lower lip vermilion show. The right lateral analysis included measurement of the anterior-most projection of the upper and lower lips.

Exclusion criteria included a concomitant chin augmentation, as well as use of injectable and/or surgical lip fillers or perioral skin resurfacing within 6 months of the preoperative photograph.

Compared with the group that did not receive lip augmentation, the mean changes from baseline in the lip augmentation group were statistically significant, reported the authors.

Comparing baseline and postprocedure photographs among the lip augmentation patients, the mean increase in upper lip projection from baseline was 0.99 mm, and in lower lip projection it was 0.90 mm. The mean increase in upper lip vermilion show from baseline was 20% on the right side and 22% on the left. The mean increase in lower lip vermilion show from baseline was 23% on the right side and 24% on the left.

Regarding complications, “there were no contour deformities, no limitations in head movement, no increased postauricular neck pain, no spinal accessory nerve injuries, and no difference in temporary numbness around the ears between the SCM graft and control group patients,” wrote the authors.

A medical chart review revealed that a deep focal lump developed in the upper lip of one SCM patient 3 years postoperatively. The etiology of the lump was unknown but it resolved after two triamcinolone acetonide injections, they reported.

“All patients were subjectively pleased with their degree of lip augmentation,” but one patient requested additional augmentation 2 years postoperatively, which was performed successfully with injectable gel, they said.

The SCM muscle and fascia graft has been performed by the authors since 1996, most commonly in conjunction with cervicofacial rhytidectomy, but also as a stand-alone procedure.

When performed with rhytidectomy, the superficial musculoaponeurotic system incision is extended inferiorly along the anterior border of the SCM muscle. Then, a segment of the SCM muscle and fascia is harvested from the mastoid process inferiorly, along the posterior border. Hemostasis is achieved with bipolar cautery, and the donor defect is closed.

After completion of the cervicofacial rhytidectomy, single incisions are made just inside the mucosa on each corner of the mouth, through which upper and lower lip tunnels are created in the superficial orbicularis oris muscle. The graft material is then pulled through the tunnels and positioned symmetrically, and the incisions are closed. “It is imperative to contour the grafts so that they are smooth and free of any muscle bulges that may be visible postoperatively,” they wrote. The grafts are intentionally left slightly longer than the distance between the incisions. “We have found that tucking the lateral ends of the grafts slightly lateral to the corner of the mouth incisions helps counteract the natural tendency for the grafts to horizontally shorten. This allows preservation of lateral lip fullness,” they explained.

After the procedure, antibiotic ointment is applied and patients are asked to limit their mouth opening for 2 weeks postoperatively.

When performed without rhytidectomy, “the same horizontal limb of the rhytidectomy incision is performed in the hair-bearing scalp to access this portion of the SCM, but the patient must be counseled about a donor site incision that would not be required with a nonautologous implant material.”

Neither dermal cysts, or prolonged stiffness or sensory changes were encountered in the study group – problems that have been reported with other lip augmentations procedures, they wrote.

“We have seen occasional asymmetries in the lips after SCM grafting,” they wrote. “Fortunately, these findings are rare,” they continued, without specifying their frequency in the study group. “There are several possible explanations for this finding: the presence of slight contour irregularities in the grafts when they are implanted; asymmetric graft compression; differential resorption with a given graft; and/or a contribution from dynamic movement of the lips.”

They study’s main limitation was some variation in the camera’s distance from the patient, although an attempt was made to control for this with the calibration of photographs, the authors wrote. In addition, they noted, patient satisfaction was not formally measured.

The researchers reported no financial disclosures.

Lip augmentation with autologous sternocleidomastoid muscle and fascia grafts results in enhanced vermilion show and lip projection up to 2 years post procedure, according to a single-center, retrospective study.

“This is another tool in the plastic surgeon’s armamentarium to combat the aging lip, which along with every other technique has some limitations, yet is effective in our practice,” wrote Dr. Anurag Agarwal, of the Aesthetic Surgery Center, Naples, Florida, and colleagues in the March/April issue of Archives of Facial Plastic Surgery.

“Based on the present study, patients who desire subtle, yet long-term lip augmentation can be counseled to expect approximately a 20% to 25% increase in vermilion show and approximately a 1-mm increase in lip projection at 2 years and longer from baseline.”

The study compared baseline and postprocedure photographs of 25 consecutive patients who underwent sternocleidomastoid (SCM) muscle and fascia augmentation of the lips with concurrent cervicofacial rhytidectomy (Arch. Facial Plast. Surg. 2010;12:97-102).

They were compared to similar baseline and postprocedure photographs of 25 control patients who received cervicofacial rhytidectomy alone, with no lip augmentation.

The mean postoperative photograph was taken at 25 months in the SCM group and 21 months in the control group. The ages of the patients were not reported.

For each patient, frontal and right lateral photographs were analyzed. The frontal analysis included measurement of the right and left, upper and lower lip vermilion show. The right lateral analysis included measurement of the anterior-most projection of the upper and lower lips.

Exclusion criteria included a concomitant chin augmentation, as well as use of injectable and/or surgical lip fillers or perioral skin resurfacing within 6 months of the preoperative photograph.

Compared with the group that did not receive lip augmentation, the mean changes from baseline in the lip augmentation group were statistically significant, reported the authors.

Comparing baseline and postprocedure photographs among the lip augmentation patients, the mean increase in upper lip projection from baseline was 0.99 mm, and in lower lip projection it was 0.90 mm. The mean increase in upper lip vermilion show from baseline was 20% on the right side and 22% on the left. The mean increase in lower lip vermilion show from baseline was 23% on the right side and 24% on the left.

Regarding complications, “there were no contour deformities, no limitations in head movement, no increased postauricular neck pain, no spinal accessory nerve injuries, and no difference in temporary numbness around the ears between the SCM graft and control group patients,” wrote the authors.

A medical chart review revealed that a deep focal lump developed in the upper lip of one SCM patient 3 years postoperatively. The etiology of the lump was unknown but it resolved after two triamcinolone acetonide injections, they reported.

“All patients were subjectively pleased with their degree of lip augmentation,” but one patient requested additional augmentation 2 years postoperatively, which was performed successfully with injectable gel, they said.

The SCM muscle and fascia graft has been performed by the authors since 1996, most commonly in conjunction with cervicofacial rhytidectomy, but also as a stand-alone procedure.

When performed with rhytidectomy, the superficial musculoaponeurotic system incision is extended inferiorly along the anterior border of the SCM muscle. Then, a segment of the SCM muscle and fascia is harvested from the mastoid process inferiorly, along the posterior border. Hemostasis is achieved with bipolar cautery, and the donor defect is closed.

After completion of the cervicofacial rhytidectomy, single incisions are made just inside the mucosa on each corner of the mouth, through which upper and lower lip tunnels are created in the superficial orbicularis oris muscle. The graft material is then pulled through the tunnels and positioned symmetrically, and the incisions are closed. “It is imperative to contour the grafts so that they are smooth and free of any muscle bulges that may be visible postoperatively,” they wrote. The grafts are intentionally left slightly longer than the distance between the incisions. “We have found that tucking the lateral ends of the grafts slightly lateral to the corner of the mouth incisions helps counteract the natural tendency for the grafts to horizontally shorten. This allows preservation of lateral lip fullness,” they explained.

After the procedure, antibiotic ointment is applied and patients are asked to limit their mouth opening for 2 weeks postoperatively.

When performed without rhytidectomy, “the same horizontal limb of the rhytidectomy incision is performed in the hair-bearing scalp to access this portion of the SCM, but the patient must be counseled about a donor site incision that would not be required with a nonautologous implant material.”

Neither dermal cysts, or prolonged stiffness or sensory changes were encountered in the study group – problems that have been reported with other lip augmentations procedures, they wrote.

“We have seen occasional asymmetries in the lips after SCM grafting,” they wrote. “Fortunately, these findings are rare,” they continued, without specifying their frequency in the study group. “There are several possible explanations for this finding: the presence of slight contour irregularities in the grafts when they are implanted; asymmetric graft compression; differential resorption with a given graft; and/or a contribution from dynamic movement of the lips.”

They study’s main limitation was some variation in the camera’s distance from the patient, although an attempt was made to control for this with the calibration of photographs, the authors wrote. In addition, they noted, patient satisfaction was not formally measured.

The researchers reported no financial disclosures.

Lip augmentation with autologous sternocleidomastoid muscle and fascia grafts results in enhanced vermilion show and lip projection up to 2 years post procedure, according to a single-center, retrospective study.

“This is another tool in the plastic surgeon’s armamentarium to combat the aging lip, which along with every other technique has some limitations, yet is effective in our practice,” wrote Dr. Anurag Agarwal, of the Aesthetic Surgery Center, Naples, Florida, and colleagues in the March/April issue of Archives of Facial Plastic Surgery.

“Based on the present study, patients who desire subtle, yet long-term lip augmentation can be counseled to expect approximately a 20% to 25% increase in vermilion show and approximately a 1-mm increase in lip projection at 2 years and longer from baseline.”

The study compared baseline and postprocedure photographs of 25 consecutive patients who underwent sternocleidomastoid (SCM) muscle and fascia augmentation of the lips with concurrent cervicofacial rhytidectomy (Arch. Facial Plast. Surg. 2010;12:97-102).

They were compared to similar baseline and postprocedure photographs of 25 control patients who received cervicofacial rhytidectomy alone, with no lip augmentation.

The mean postoperative photograph was taken at 25 months in the SCM group and 21 months in the control group. The ages of the patients were not reported.

For each patient, frontal and right lateral photographs were analyzed. The frontal analysis included measurement of the right and left, upper and lower lip vermilion show. The right lateral analysis included measurement of the anterior-most projection of the upper and lower lips.

Exclusion criteria included a concomitant chin augmentation, as well as use of injectable and/or surgical lip fillers or perioral skin resurfacing within 6 months of the preoperative photograph.

Compared with the group that did not receive lip augmentation, the mean changes from baseline in the lip augmentation group were statistically significant, reported the authors.

Comparing baseline and postprocedure photographs among the lip augmentation patients, the mean increase in upper lip projection from baseline was 0.99 mm, and in lower lip projection it was 0.90 mm. The mean increase in upper lip vermilion show from baseline was 20% on the right side and 22% on the left. The mean increase in lower lip vermilion show from baseline was 23% on the right side and 24% on the left.

Regarding complications, “there were no contour deformities, no limitations in head movement, no increased postauricular neck pain, no spinal accessory nerve injuries, and no difference in temporary numbness around the ears between the SCM graft and control group patients,” wrote the authors.

A medical chart review revealed that a deep focal lump developed in the upper lip of one SCM patient 3 years postoperatively. The etiology of the lump was unknown but it resolved after two triamcinolone acetonide injections, they reported.

“All patients were subjectively pleased with their degree of lip augmentation,” but one patient requested additional augmentation 2 years postoperatively, which was performed successfully with injectable gel, they said.

The SCM muscle and fascia graft has been performed by the authors since 1996, most commonly in conjunction with cervicofacial rhytidectomy, but also as a stand-alone procedure.

When performed with rhytidectomy, the superficial musculoaponeurotic system incision is extended inferiorly along the anterior border of the SCM muscle. Then, a segment of the SCM muscle and fascia is harvested from the mastoid process inferiorly, along the posterior border. Hemostasis is achieved with bipolar cautery, and the donor defect is closed.

After completion of the cervicofacial rhytidectomy, single incisions are made just inside the mucosa on each corner of the mouth, through which upper and lower lip tunnels are created in the superficial orbicularis oris muscle. The graft material is then pulled through the tunnels and positioned symmetrically, and the incisions are closed. “It is imperative to contour the grafts so that they are smooth and free of any muscle bulges that may be visible postoperatively,” they wrote. The grafts are intentionally left slightly longer than the distance between the incisions. “We have found that tucking the lateral ends of the grafts slightly lateral to the corner of the mouth incisions helps counteract the natural tendency for the grafts to horizontally shorten. This allows preservation of lateral lip fullness,” they explained.

After the procedure, antibiotic ointment is applied and patients are asked to limit their mouth opening for 2 weeks postoperatively.

When performed without rhytidectomy, “the same horizontal limb of the rhytidectomy incision is performed in the hair-bearing scalp to access this portion of the SCM, but the patient must be counseled about a donor site incision that would not be required with a nonautologous implant material.”

Neither dermal cysts, or prolonged stiffness or sensory changes were encountered in the study group – problems that have been reported with other lip augmentations procedures, they wrote.

“We have seen occasional asymmetries in the lips after SCM grafting,” they wrote. “Fortunately, these findings are rare,” they continued, without specifying their frequency in the study group. “There are several possible explanations for this finding: the presence of slight contour irregularities in the grafts when they are implanted; asymmetric graft compression; differential resorption with a given graft; and/or a contribution from dynamic movement of the lips.”

They study’s main limitation was some variation in the camera’s distance from the patient, although an attempt was made to control for this with the calibration of photographs, the authors wrote. In addition, they noted, patient satisfaction was not formally measured.

The researchers reported no financial disclosures.

QUEBEC CITY — The increased rate of serious infections seen in patients with rheumatoid arthritis is most strongly associated with current glucocorticoid exposure, but comorbidities are also an important factor, according to findings from a large, nested, case-control study presented at the annual meeting of the Canadian Rheumatology Association.

“When we try to predict risk of infection, we tend to focus on the drugs, particularly the immunosuppressive agents,” principal investigator Dr. Claire Bombardier said in an interview. The findings from this research show that physicians need to pay more attention to other, heretofore largely overlooked risk factors, she added.

Dr. Bombardier noted that her study was limited by its reliance on data from a source that does not include complete information on exposure to biologic agents. Use of biologics has been linked to an increased risk for reactivation of tuberculosis as well as primary fungal and other infections.

In two separate posters, Dr. Bombardier presented a retrospective examination of serious infections requiring hospitalization, as well as serious fungal infections, in a cohort of 81,497 seniors with RA.

All subjects were aged older than 65 years (mean, 69 years), and were drawn from the Ontario Biologics Research Initiative administrative database, said Dr. Bombardier, professor of medicine and director of the division of rheumatology at the University of Toronto.

The first study included 14,214 patients with serious infection requiring hospitalization in 1992-2006, with the most common infection being pneumonia (7,026 patients). These subjects were matched to controls from the same cohort according to age, sex, and year of cohort entry.

Multivariate logistic regression analysis was used to assess the independent effects of demographics (age, income, rural/urban residence), comorbidity (based on the Charlson-Deyo comorbidity index), markers of RA severity (number of rheumatology visits, history of joint replacement, presence of extra-articular RA, and prescription NSAID use), and RA-related drug exposure.

Past and current drug exposures were determined based on electronic provincial prescription data, although most biologic use was probably not captured in this database because it is not covered by provincial health insurance.

After adjustment, the study found that current use of glucocorticoids was associated with the highest risk of infection, and that this risk increased with increasing doses. Compared with no exposure, a glucocorticoid dose of 5 mg or less per day was associated with an odds ratio of infection of 3.81. At 6-9 mg/day, the OR was 4.56, rising to 5.58 at a dose of 10-19 mg/day, and 5.46 at a dose of 20 mg or more per day.

Other drugs—both biologics (to the extent their effect was assessed) and disease-modifying antirheumatic drugs—were also associated with risk, but less so, with ORs ranging from 1.1 to 3.64, Dr. Bombardier said.

Within the context of these nonglucocorticoid drugs, comorbidity and markers of disease severity were associated with a similar range of risks of infection. Chronic lung disease was associated with an OR of 1.47, and renal disease with OR of 1.38. The Charlson-Deyo comorbidity index score of 1 had an OR of 1.44, whereas a score of 2 or more had an OR of 1.59.

In terms of markers of disease activity, the presence of one or more extra-articular feature of RA was associated with an OR of 1.14, and a history of joint replacement with an OR of 1.05.

Dr. Bombardier's second study focused specifically on the risk of serious fungal infections within the same cohort, because of “the flurry of interest in fungal infections recently,” she said.

A total of 53 serious fungal infections occurred within the cohort, including aspergillosis, coccidioidomycosis, histoplasmosis, blastomycosis, paracoccidioidomycosis, and systemic candidiasis. As with the previous study, cases of infection were matched to 265 controls from the same cohort.

Again, univariate and multivariate logistic regression analysis assessed the independent effects of demographics, comorbidity, markers of RA severity, and RA-related drug exposure.

After adjustment, the study found that cases were more likely than controls to live in rural areas (OR, 6.8) and to have more comorbidity, most commonly lung (OR, 1.27) and renal disease (OR, 1.95).

Compared with no prednisone, there was a greater risk of fungal infection associated with prednisone doses of 10-19 mg/day (OR, 1.90) and more than 20 mg/day (OR, 4.0).

Only 17 of 53 cases were currently exposed to a DMARD at the time of the fungal infection, and no case was currently exposed to a biologic agent.

Compared with no exposure, a higher risk of infection was associated with current exposure to sulfasalazine (OR, 1.90), methotrexate (OR, 1.66), and hydroxychloroquine (OR, 1.64).

Dr. Bombardier said this information should help physicians refine decision making about adjusting RA patients' medication dose.

“When you're worrying about a patient, don't focus just on the drugs. Think about whether they have renal disease, or whether they have lung disease. That is as important [as], if not more important than, worrying about the drugs,” she said.

Disclosures: Funding for the study was provided by the Canadian Institute of Health Research and the Ontario Ministry of Health and Long-Term Care. Dr. Bombardier holds a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care.

QUEBEC CITY — The increased rate of serious infections seen in patients with rheumatoid arthritis is most strongly associated with current glucocorticoid exposure, but comorbidities are also an important factor, according to findings from a large, nested, case-control study presented at the annual meeting of the Canadian Rheumatology Association.

“When we try to predict risk of infection, we tend to focus on the drugs, particularly the immunosuppressive agents,” principal investigator Dr. Claire Bombardier said in an interview. The findings from this research show that physicians need to pay more attention to other, heretofore largely overlooked risk factors, she added.

Dr. Bombardier noted that her study was limited by its reliance on data from a source that does not include complete information on exposure to biologic agents. Use of biologics has been linked to an increased risk for reactivation of tuberculosis as well as primary fungal and other infections.

In two separate posters, Dr. Bombardier presented a retrospective examination of serious infections requiring hospitalization, as well as serious fungal infections, in a cohort of 81,497 seniors with RA.

All subjects were aged older than 65 years (mean, 69 years), and were drawn from the Ontario Biologics Research Initiative administrative database, said Dr. Bombardier, professor of medicine and director of the division of rheumatology at the University of Toronto.

The first study included 14,214 patients with serious infection requiring hospitalization in 1992-2006, with the most common infection being pneumonia (7,026 patients). These subjects were matched to controls from the same cohort according to age, sex, and year of cohort entry.

Multivariate logistic regression analysis was used to assess the independent effects of demographics (age, income, rural/urban residence), comorbidity (based on the Charlson-Deyo comorbidity index), markers of RA severity (number of rheumatology visits, history of joint replacement, presence of extra-articular RA, and prescription NSAID use), and RA-related drug exposure.

Past and current drug exposures were determined based on electronic provincial prescription data, although most biologic use was probably not captured in this database because it is not covered by provincial health insurance.

After adjustment, the study found that current use of glucocorticoids was associated with the highest risk of infection, and that this risk increased with increasing doses. Compared with no exposure, a glucocorticoid dose of 5 mg or less per day was associated with an odds ratio of infection of 3.81. At 6-9 mg/day, the OR was 4.56, rising to 5.58 at a dose of 10-19 mg/day, and 5.46 at a dose of 20 mg or more per day.

Other drugs—both biologics (to the extent their effect was assessed) and disease-modifying antirheumatic drugs—were also associated with risk, but less so, with ORs ranging from 1.1 to 3.64, Dr. Bombardier said.

Within the context of these nonglucocorticoid drugs, comorbidity and markers of disease severity were associated with a similar range of risks of infection. Chronic lung disease was associated with an OR of 1.47, and renal disease with OR of 1.38. The Charlson-Deyo comorbidity index score of 1 had an OR of 1.44, whereas a score of 2 or more had an OR of 1.59.

In terms of markers of disease activity, the presence of one or more extra-articular feature of RA was associated with an OR of 1.14, and a history of joint replacement with an OR of 1.05.

Dr. Bombardier's second study focused specifically on the risk of serious fungal infections within the same cohort, because of “the flurry of interest in fungal infections recently,” she said.

A total of 53 serious fungal infections occurred within the cohort, including aspergillosis, coccidioidomycosis, histoplasmosis, blastomycosis, paracoccidioidomycosis, and systemic candidiasis. As with the previous study, cases of infection were matched to 265 controls from the same cohort.

Again, univariate and multivariate logistic regression analysis assessed the independent effects of demographics, comorbidity, markers of RA severity, and RA-related drug exposure.

After adjustment, the study found that cases were more likely than controls to live in rural areas (OR, 6.8) and to have more comorbidity, most commonly lung (OR, 1.27) and renal disease (OR, 1.95).

Compared with no prednisone, there was a greater risk of fungal infection associated with prednisone doses of 10-19 mg/day (OR, 1.90) and more than 20 mg/day (OR, 4.0).

Only 17 of 53 cases were currently exposed to a DMARD at the time of the fungal infection, and no case was currently exposed to a biologic agent.

Compared with no exposure, a higher risk of infection was associated with current exposure to sulfasalazine (OR, 1.90), methotrexate (OR, 1.66), and hydroxychloroquine (OR, 1.64).

Dr. Bombardier said this information should help physicians refine decision making about adjusting RA patients' medication dose.

“When you're worrying about a patient, don't focus just on the drugs. Think about whether they have renal disease, or whether they have lung disease. That is as important [as], if not more important than, worrying about the drugs,” she said.

Disclosures: Funding for the study was provided by the Canadian Institute of Health Research and the Ontario Ministry of Health and Long-Term Care. Dr. Bombardier holds a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care.

QUEBEC CITY — The increased rate of serious infections seen in patients with rheumatoid arthritis is most strongly associated with current glucocorticoid exposure, but comorbidities are also an important factor, according to findings from a large, nested, case-control study presented at the annual meeting of the Canadian Rheumatology Association.

“When we try to predict risk of infection, we tend to focus on the drugs, particularly the immunosuppressive agents,” principal investigator Dr. Claire Bombardier said in an interview. The findings from this research show that physicians need to pay more attention to other, heretofore largely overlooked risk factors, she added.

Dr. Bombardier noted that her study was limited by its reliance on data from a source that does not include complete information on exposure to biologic agents. Use of biologics has been linked to an increased risk for reactivation of tuberculosis as well as primary fungal and other infections.

In two separate posters, Dr. Bombardier presented a retrospective examination of serious infections requiring hospitalization, as well as serious fungal infections, in a cohort of 81,497 seniors with RA.

All subjects were aged older than 65 years (mean, 69 years), and were drawn from the Ontario Biologics Research Initiative administrative database, said Dr. Bombardier, professor of medicine and director of the division of rheumatology at the University of Toronto.

The first study included 14,214 patients with serious infection requiring hospitalization in 1992-2006, with the most common infection being pneumonia (7,026 patients). These subjects were matched to controls from the same cohort according to age, sex, and year of cohort entry.

Multivariate logistic regression analysis was used to assess the independent effects of demographics (age, income, rural/urban residence), comorbidity (based on the Charlson-Deyo comorbidity index), markers of RA severity (number of rheumatology visits, history of joint replacement, presence of extra-articular RA, and prescription NSAID use), and RA-related drug exposure.

Past and current drug exposures were determined based on electronic provincial prescription data, although most biologic use was probably not captured in this database because it is not covered by provincial health insurance.

After adjustment, the study found that current use of glucocorticoids was associated with the highest risk of infection, and that this risk increased with increasing doses. Compared with no exposure, a glucocorticoid dose of 5 mg or less per day was associated with an odds ratio of infection of 3.81. At 6-9 mg/day, the OR was 4.56, rising to 5.58 at a dose of 10-19 mg/day, and 5.46 at a dose of 20 mg or more per day.

Other drugs—both biologics (to the extent their effect was assessed) and disease-modifying antirheumatic drugs—were also associated with risk, but less so, with ORs ranging from 1.1 to 3.64, Dr. Bombardier said.

Within the context of these nonglucocorticoid drugs, comorbidity and markers of disease severity were associated with a similar range of risks of infection. Chronic lung disease was associated with an OR of 1.47, and renal disease with OR of 1.38. The Charlson-Deyo comorbidity index score of 1 had an OR of 1.44, whereas a score of 2 or more had an OR of 1.59.

In terms of markers of disease activity, the presence of one or more extra-articular feature of RA was associated with an OR of 1.14, and a history of joint replacement with an OR of 1.05.

Dr. Bombardier's second study focused specifically on the risk of serious fungal infections within the same cohort, because of “the flurry of interest in fungal infections recently,” she said.

A total of 53 serious fungal infections occurred within the cohort, including aspergillosis, coccidioidomycosis, histoplasmosis, blastomycosis, paracoccidioidomycosis, and systemic candidiasis. As with the previous study, cases of infection were matched to 265 controls from the same cohort.

Again, univariate and multivariate logistic regression analysis assessed the independent effects of demographics, comorbidity, markers of RA severity, and RA-related drug exposure.

After adjustment, the study found that cases were more likely than controls to live in rural areas (OR, 6.8) and to have more comorbidity, most commonly lung (OR, 1.27) and renal disease (OR, 1.95).

Compared with no prednisone, there was a greater risk of fungal infection associated with prednisone doses of 10-19 mg/day (OR, 1.90) and more than 20 mg/day (OR, 4.0).

Only 17 of 53 cases were currently exposed to a DMARD at the time of the fungal infection, and no case was currently exposed to a biologic agent.

Compared with no exposure, a higher risk of infection was associated with current exposure to sulfasalazine (OR, 1.90), methotrexate (OR, 1.66), and hydroxychloroquine (OR, 1.64).

Dr. Bombardier said this information should help physicians refine decision making about adjusting RA patients' medication dose.

“When you're worrying about a patient, don't focus just on the drugs. Think about whether they have renal disease, or whether they have lung disease. That is as important [as], if not more important than, worrying about the drugs,” she said.

Disclosures: Funding for the study was provided by the Canadian Institute of Health Research and the Ontario Ministry of Health and Long-Term Care. Dr. Bombardier holds a Canada Research Chair in Knowledge Transfer for Musculoskeletal Care.

MONTREAL — Injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a case-control study.

“All we're talking about here is an association. We can't infer causation,” the study's principal investigator, Dr. Dafna Gladman, said in an interview.

Previous, less-rigorous studies have suggested an association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto. “This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said.

At most, 30% of psoriasis patients go on to develop PsA, Dr. Gladman noted.

Her study, presented as a poster at the annual meeting of the Canadian Rheumatology Association, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone.

Men accounted for a similar percentage of both study groups (46% in the PsA group and 44% in the control group). The mean age of the participants in each group was similar (45 years and 48 years), as was the mean duration of psoriasis (17.5 years and 18.5 years). The mean duration of PsA was 3 years. All the patients with psoriasis were examined to ensure they didn't have psoriatic arthritis.

All of the patients completed a questionnaire to assess environmental factors during the past 10 years, including occupational trauma, infection, immunization, smoking, and psychological stress.

In a univariate analysis, a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an odds ratio of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8. The third-highest risk factor was any injury requiring medical attention (OR, 2.43).

In a multivariate logistic regression analysis, progression from psoriasis to PsA was significantly associated with severe infection requiring hospitalization (OR, 10.6), occupations requiring the lifting of heavy loads (OR, 2.7), and injuries requiring medical attention (excluding fractures and motor vehicle accidents) (OR, 2.3).

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” she said.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress. In fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis,” Dr. Gladman commented.

In the multivariate analysis, smoking appeared to have a significant association with decreased risk, she added. Current smoking had an OR of 0.4 and past smoking had an OR of 0.5.

The findings are too preliminary to guide clinical practice at this time, Dr. Gladman said.

Still, psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.”

The next step should be to look at the possible role of genetic and environmental factors, she added.

Disclosures: Dr. Gladman declared no conflicts of interest.

MONTREAL — Injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a case-control study.

“All we're talking about here is an association. We can't infer causation,” the study's principal investigator, Dr. Dafna Gladman, said in an interview.

Previous, less-rigorous studies have suggested an association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto. “This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said.

At most, 30% of psoriasis patients go on to develop PsA, Dr. Gladman noted.

Her study, presented as a poster at the annual meeting of the Canadian Rheumatology Association, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone.

Men accounted for a similar percentage of both study groups (46% in the PsA group and 44% in the control group). The mean age of the participants in each group was similar (45 years and 48 years), as was the mean duration of psoriasis (17.5 years and 18.5 years). The mean duration of PsA was 3 years. All the patients with psoriasis were examined to ensure they didn't have psoriatic arthritis.

All of the patients completed a questionnaire to assess environmental factors during the past 10 years, including occupational trauma, infection, immunization, smoking, and psychological stress.

In a univariate analysis, a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an odds ratio of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8. The third-highest risk factor was any injury requiring medical attention (OR, 2.43).

In a multivariate logistic regression analysis, progression from psoriasis to PsA was significantly associated with severe infection requiring hospitalization (OR, 10.6), occupations requiring the lifting of heavy loads (OR, 2.7), and injuries requiring medical attention (excluding fractures and motor vehicle accidents) (OR, 2.3).

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” she said.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress. In fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis,” Dr. Gladman commented.

In the multivariate analysis, smoking appeared to have a significant association with decreased risk, she added. Current smoking had an OR of 0.4 and past smoking had an OR of 0.5.

The findings are too preliminary to guide clinical practice at this time, Dr. Gladman said.

Still, psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.”

The next step should be to look at the possible role of genetic and environmental factors, she added.

Disclosures: Dr. Gladman declared no conflicts of interest.

MONTREAL — Injury, heavy lifting, severe infection, or other forms of trauma were associated with the progression of psoriasis to psoriatic arthritis in a case-control study.

“All we're talking about here is an association. We can't infer causation,” the study's principal investigator, Dr. Dafna Gladman, said in an interview.

Previous, less-rigorous studies have suggested an association between trauma and psoriatic arthritis (PsA), said Dr. Gladman, professor of medicine at the University of Toronto. “This study supports that notion—that environmental factors are important—but we think genetic factors are also involved,” as well as immunologic factors, she said.

At most, 30% of psoriasis patients go on to develop PsA, Dr. Gladman noted.

Her study, presented as a poster at the annual meeting of the Canadian Rheumatology Association, compared 159 patients who had PsA with the same number of control patients who had psoriasis alone.

Men accounted for a similar percentage of both study groups (46% in the PsA group and 44% in the control group). The mean age of the participants in each group was similar (45 years and 48 years), as was the mean duration of psoriasis (17.5 years and 18.5 years). The mean duration of PsA was 3 years. All the patients with psoriasis were examined to ensure they didn't have psoriatic arthritis.

All of the patients completed a questionnaire to assess environmental factors during the past 10 years, including occupational trauma, infection, immunization, smoking, and psychological stress.

In a univariate analysis, a history of infection requiring hospitalization was the strongest risk factor for the development of PsA, with an odds ratio of 11.7. (Infective diarrhea carried an OR of 2.11.)

The second-highest risk factor was in the category of occupational exposure. A history of work involving cumulative lifting of at least 100 lb/hr carried an OR of 2.9, and pushing cumulative loads of at least 200 lb/hr carried an OR of 1.8. The third-highest risk factor was any injury requiring medical attention (OR, 2.43).

In a multivariate logistic regression analysis, progression from psoriasis to PsA was significantly associated with severe infection requiring hospitalization (OR, 10.6), occupations requiring the lifting of heavy loads (OR, 2.7), and injuries requiring medical attention (excluding fractures and motor vehicle accidents) (OR, 2.3).

“For exposure to immunizations we found no risk, but another group [of investigators] has found that immunization was higher in those who got arthritis,” she said.

“And psychological stress had no impact, although it has been reported that psoriatic patients without arthritis have a lot of stress. In fact, they may even have more because it turns out that patients with psoriasis and no arthritis actually have worse psoriasis,” Dr. Gladman commented.

In the multivariate analysis, smoking appeared to have a significant association with decreased risk, she added. Current smoking had an OR of 0.4 and past smoking had an OR of 0.5.

The findings are too preliminary to guide clinical practice at this time, Dr. Gladman said.

Still, psoriasis patients should know that “if you have a job that requires a lot of lifting, you are more susceptible to getting psoriatic arthritis. Whether it's the only factor, we don't know, because there are also genetic factors involved. It's quite possible that in those people who are genetically predisposed, if they also do this work, they are more likely to get arthritis.”

The next step should be to look at the possible role of genetic and environmental factors, she added.

Disclosures: Dr. Gladman declared no conflicts of interest.