Michele G. Sullivan

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – A 15-day titration is usually the most economical and convenient way to identify the optimal dose of attention-deficit/hyperactivity disorder medications.

Starting children on a low dose and waiting up to a month before reassessing wastes time and money, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"You don’t need a month at a low dose to see what’s happening," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. "You generally need 5-7 days on a dose to assess any response. Any less than that and you might have a random good day or a random bad day. You want enough behaviors to see what’s really going on and to get a little bit of tolerance to any side effects."

Dr. McGough backs a more rapid titration schedule than that typically recommended by the Food and Drug Administration for most ADHD medications. The schedule stays within the limits imposed by the Drug Enforcement Administration, while expediently getting children to an effective dose.

After an assessment and drug selection, he writes an initial prescription for a month’s worth of the drug. Parents receive a titration schedule. A typical schedule calls for starting with one pill for 5 days, two for the next 5 days, and three for the last 5 days, with a follow-up appointment around 2-3 weeks.

"This takes children through the dose range and lets you see how they respond to each dose. I try them over a reasonable range of dose and when they find one that works, I try it for 1 month. If it’s successful, I give them 3 months of medication, which I’m allowed to do in my state."

Education is important for parents and children. But Dr. McGough tells families not to worry too much about any mild treatment-related side effects. "I tell them there might be a little stomach ache or headache, but that we’ll address this in just a couple of weeks. The real message is that you don’t want to waste your time or the patients’ time."

Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi & Co., Shire Pharamceuticals Inc., and Supernus Pharmaceuticals, and is a consultant for Alexa Pharmaceuticals and Medimmune.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – With new national data finding that 17% of the country’s youngsters are obese, physicians who treat children with antipsychotics face even tougher medication choices.

Because many of the drugs are tied to increases in weight and obesity-driven diseases, it’s not hard to see the looming metabolic train wreck, Dr. Christoph U. Correll said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The newest NHANES (National Health and Nutrition Survey), released in January, found that more than one-third of U.S. adults and almost 17% of youth were classified as obese in 2009-2010.

"We are now seeing obese children with type 2 diabetes, and we know that this disease has the same 8-year risk as a myocardial infarction for [another] heart attack," said Dr. Correll of the Zucker Hillside Hospital in Glen Oak, N.Y. "We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

Studies agree that many antipsychotic medications are associated with significant weight gain, much of that leading to metabolic syndrome, Dr. Correll said. A 2011 meta-analysis of 3,000 children found that those taking olanzapine gained almost 4 kg within just 1 month of starting the medication (Euro. Psychiatry 2011:26:144-58). Quetiapine was associated with a gain of 2 kg over 4 weeks, and risperidone with a gain of 2 kg over 7 weeks. Patients taking aripiprazole gained 1 kg over 6 weeks, whereas those taking a placebo had no weight change.

"We will see obese children who will not outlive their parents, and we must admit that our treatments are contributing to this."

This phenomenon is directly related to the onset of metabolic syndrome, and its associated cardiovascular risks of lipid abnormalities and hypertension, Dr. Correll said. "The longer you treat, the higher are these rates. And the longer you have cardiovascular risk factors, the greater your chance of death."

A 2006 study illustrates his point. By 10 years of treatment, 21% of patients had metabolic syndrome; by 20 years of treatment, 34%, and after 20 years, 39%.

Age played a significant role, as expected, but a significant difference was found between the general population and patients taking the drugs. Among patients aged 35-45 years, 35% had metabolic syndrome, compared with 6.5% of nonpatients. By 55 years, the prevalence had doubled in the general population, to about 14%, while it increased significantly less in patients, to 38%.

"This shows that we are shifting the metabolic burden to earlier in life. These patients are prematurely metabolically demented, and we are doing this by not taking care of their weight and metabolic problems."

This leaves psychiatrists on the horns of a dilemma, Dr. Correll said. Patients need treatment, but the drugs come with a high physiological price. To decrease patients’ exposure to metabolic risks, he advises starting treatment with the lowest metabolically driven medications, and moving to other drugs only if the less risky ones aren’t controlling symptoms.

Studies suggest that, in most patients, olanzapine confers the greatest risk of weight gain, and risperidone the lowest. Lurasidone is doing "quite well" in adult studies, as far as weight gain goes (Drugs Today [Barc.] 2011;47:807-16), but it has not been examined in children or adolescents. "I think this is something we as pediatric psychiatrists should be trying to get our hands on," Dr. Correll said.

A newly published, randomized trial suggests that valproate might change some of the metabolic activity that drives weight gain in patients taking antipsychotic medications.

Patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder were randomized to olanzapine or risperidone alone, or to either of the drugs plus valproate as a mood stabilizer. Every one of those taking olanzapine plus valproate experienced significant weight gains, whereas the weight gain occurred in 60% of those taking olanzapine alone.

Weight gain was less common in both risperidone groups. But the addition of valproate seemed to enhance risperidone’s weight-neutral effect: Some 15% of those taking the combination gained significant amounts of weight – significantly fewer than the 30% who gained weight on risperidone alone (J. Clin. Psychiatry 2011;72:1602-10).

The same pattern held with other metabolic measures, including changes in body mass index, glycosylated hemoglobin, total cholesterol, and the triglyceride/HDL cholesterol ratio.

The findings point out just how much remains unknown about the metabolic effects of antipsychotic medications. For now, Dr. Correll said, the best path is to start with the lowest metabolically active drug appropriate for that patient, and closely monitor any metabolic changes.

"At each visit, obtain both weight and body mass index," he said. "Measure waist circumference at least once a year, and provide counseling on diet and exercise."

Dr. Correll disclosed that he is a consultant for and is on the advisory boards of numerous drug companies, and also receives research support and honoraria from many of them.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – Psychiatrists and primary care providers who care for the mental health needs of children and adolescents can find research-driven online tools to help.

The American Academy of Child and Adolescent Psychiatry (AACAP) has a wealth of free information available to these physicians – whether they want to integrate mental health services into their practices or simply stay current on the latest research and medications.

The online tool kits contain everything from psychiatric rating scales and expert videos to handouts for parents and children, Dr. Laurence Greenhill said at the AACAP’s 2012 psychopharmacology update.

All of the materials are backed by the most current data, eliminating the confusion of conflicting online information, said Dr. Greenhill, a child and adolescent psychiatrist who practices in New York. "These distill the elements of our work into a form that answers parents’ questions in an understandable way and refers them to websites we can approve. There is so much controversial information out there that families are often confused, and [such confusion] makes it much more difficult to counsel" them.

The online resources represent a long collaboration with the American Psychiatric Association, he said. All are readily available, even to nonmembers, and the AACAP will launch more in the coming year.

The following are some of the resources that are available for physicians:

• Compendium of rating scales. These include parent and teacher behavior rating scales, a current symptom rating scale, and the Johns Hopkins Depression Index (http://www.aacap.org/cs/clinical_care_quality_improvement/rating_scales).

• Clinical practice webinars. These include webinars on child welfare, working with the education system, and partnering with the AACAP (http://www.aacap.org/cs/business_of_practice/practice_webinars).

• Continuing medical education courses. These courses on attention-deficit/hyperactivity disorder (ADHD), including video, are taught by nationally recognized experts in the field, and are free of charge (http://www.aacap.org/cs/onlinecme).

• Clinical practice forms. These include HIPAA (Health Insurance Portability and Accountability Act) releases, medication records, school medication release, and progress notes (http://www.aacap.org/cs/business_of_practice/practice_forms_hipaa_disclosures).

• Reimbursement information. This includes the CPT codes and a training seminar (http://www.aacap.org/cs/root/member_information/practice_information/cpt_codes_information_and_module).

• Calculators. Body mass index percentile and z scores are important for tracking both decreased growth in the presence of stimulant medication and excess weight gain in the presence of antidepressants and antipsychotics (http://www.bcm.edu/cnrc/bodycomp/bmiz2.html).

• Links to growth charts. These include the World Health Organization’s growth charts for infants, and the Centers for Disease Control and Prevention’s growth chart for children aged 2 years and older (http://www.cdc.gov/growthcharts/).

The following is a listing of resources that are available for patients:

• "Facts for Families." This comprehensive handbook contains parent-friendly information on childhood psychiatric disorders. Handout is available in English, Spanish, Malaysian, Polish, Icelandic, Arabic, Urdu, and Hebrew (http://www.aacap.org/cs/root/facts_for_families/facts_for_families).

• Medication guides. These are aimed at parents of children with ADHD, depression, and bipolar disorder (http://www.parentsmedguide.org/).

Dr. Greenhill disclosed that he has received research support from Rhodes Pharmaceuticals and Shire Pharmaceuticals Inc.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.

NEW YORK – "Start low, go slow" is the typical mantra of child psychopharmacology, but it might do an enormous disservice to children with anxiety disorders.

While antidepressants can really help these children, most physicians use far too low a dose to effectively control symptoms, Dr. John T. Walkup said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

"If you use too low a dose, you won’t get the quality of effect that you could," said Dr. Walkup, vice chair of child and adolescent psychiatry at the New York–Presbyterian Hospital/Weill Cornell Medical Center. "This leaves kids with the stigma of being on medicine and the stigma of having residual treatment. I can’t think of anything meaner to do to a kid. Please, please, think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

Selective serotonin reuptake inhibitors (SSRIs) have proven benefits for anxious children, but almost no one doses young patients in the studied amounts, he said. The Child/Adolescent Anxiety Multimodal Study is an example of successful higher SSRI doses (N. Engl. J. Med. 2008;359:2753-66).

"Please, please think about pushing the doses of these medicines so that you give kids a chance to respond the best that they can."

The 12-week trial randomized 488 children with anxiety disorders to cognitive-behavioral therapy, sertraline, or a combination of both. The dosing design was flexible; physicians were told to increase the dose until symptoms remitted or side effects occurred.

"This was a forced titration. We started on 25 mg/day for a week, went to 50 mg/day the second week, sat there for a month, and then titrated up to 100 mg and 150 mg. As soon as we saw side effects, or if the child was in remission, we backed down."

After 12 weeks, the average daily sertraline dose in the combination group was 134 mg/day. In the sertraline-only group, two children withdrew from treatment because of an adverse effect. In the combination group, there were no adverse effect withdrawals. The drug was effective – 60% of children in the medication-only group improved significantly, as did 81% of those in the combination therapy group.

But the final sertraline dose was up to five times higher than the 25-37.5 mg/day dose commonly used in the psychiatric community, Dr. Walkup said. "At that low a dose, you’re going to have a lot of partial treatments and incomplete remissions. The kind of titration seen in the successful clinical trials pushes you to the highest safe dose, while most of what clinicians seek is the lowest effective dose. The problem with that is that you undershoot, undertreat, and leave kids crippled by partial recovery."

Dr. Walkup advises a literature review for physicians unfamiliar with forced titration of SSRIs. "Look at the trials and if you are not dosing in the time frame and dosages used in those trials, you are probably going too slow and too low. Think of where you should be before you call a drug a failure and stop it."

Another hurdle for some is off-label prescribing, he noted. The Food and Drug Administration has approved four SSRIs for obsessive-compulsive disorder and two for depression. But none of the drugs are approved for non–obsessive-compulsive disorder anxiety.

Despite the positive studies, "The chance that any of these drugs is ever going to be FDA-approved is slim to none," Dr. Walkup said. "So if you’re going to follow the evidence in treating childhood anxiety, you’re going to be prescribing off-label and you will have to be comfortable with that."

Dr. Walkup disclosed that he is a consultant for Shire Pharmaceuticals and has received research support from Abbott Laboratories, Lilly, and Pfizer.

A major shift in the way the federal government funds state HIV programs is likely to mean more dollars for HIV testing and treatment at the expense of funds to help prevent the disease from developing in the first place among high-risk populations.

The $339 million funding package – about the same amount as in last year’s total – reallocates federal monies by awarding health department grants based on the number of HIV-infected people living in the locality. That means areas with many cases will gain, but areas with fewer cases are going to lose – and some will lose big, said Dr. Donna Sweet, chair of the American Academy of HIV Medicine’s Board of Regents.

The redistribution may actually penalize areas with successful programs, she said in an interview, because years of prevention services and education have decreased their HIV-positive population.

Courtesy KU Internal Medicine Midtown Clinic

"Part of the National HIV/AIDS Strategy is to go where the epidemic is, and by definition to do that you are shifting money, taking it from areas that are doing a great job. But without that money, these low-incidence places run the risk of losing their edge and swinging back toward becoming high-incidence places," Dr. Sweet said.

Prior funding packages were based on the number of AIDS cases. That scenario doesn’t reflect today’s epidemiology, because antiretroviral drugs have cut down on full-blown AIDS cases. Funding based on diagnosis channels the money more effectively, Dr. Kevin Fenton said in a press statement.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever," said Dr. Fenton, director of the Centers for Disease Control and Prevention’s (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. "This new approach to prevention funding is designed to focus on the places where needs are most urgent, and on the programs that will have the most far-reaching impact. It will help us achieve the ambitious goals of the National HIV/AIDS Strategy with the efficiency and urgency the HIV epidemic demands."

Most of the federal money is for increased HIV testing and to link HIV-positive patients to medical care, according to the CDC. The new program will be phased-in over 5 years, with most of this year’s money already promised. A small portion – $20 million – will be awarded this spring to jurisdictions that institute "unique, promising demonstration projects," but standard programs aren’t eligible for that money.

"This new shift in funding to high-impact jurisdictions is leaving lower-impact areas with less," said Murray Penner, deputy director of the National Alliance of State and Territorial AIDS Directors.

"It concerns us that these programs are getting cut. We don’t know what the impact will be. Will it be like the syphilis issue, when we put money into it and it declined, only to reappear when the financial focus went away?"

The group is still calculating the new program’s state-by-state impact. But two states, Hawaii and Iowa, have been particularly hard hit, he said. Both have a low incidence of HIV-infected residents, with about 1,000 new cases each year in Hawaii and just a few hundred in Iowa. But both also have had strong prevention programs for high-risk HIV-negative residents, programs that will now disappear.

Hawaii will endure a 50% federal funding cut by 2016, at which point the new allocation program is expected to be fully implemented. The drop doesn’t account for staff wage increases, lab fees, and transportation costs – a big-ticket item in a multi-island state, said Peter Whiticar, chief of the state’s STD/AIDS Prevention Branch.

The new priority on testing and treatment means that Hawaii and other states must change their HIV focus from behavioral interventions for high-risk HIV-negative clients to medical interventions for the HIV-positive. Although both strategies are key weapons in the HIV fight, health departments may now be forced to focus on one to the detriment of the other. "We simply will not be doing any more behavioral interventions" for HIV-negative at-risk clients, Mr. Whiticar said.

And the federal grant money isn’t just for HIV/AIDS, he pointed out. It also covers services for STD and hepatitis A – an integration that CDC pushed for in the past. This made sense, because the same risky behaviors increase the chance of all these illnesses, and the strategy helped a diverse group of people, Mr. Whiticar said. But because the majority of HIV patients are men, the new funding shift cuts sexual health services for women and transgendered people, he added.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever."

"When you get this kind of funding emphasis on single service, the others start to fall by the wayside. Where the rubber hits the road is that small-incidence states still need to provide the same kind of services as high-incidence states."

Iowa is in a similar situation. The state will lose 55% of its government HIV funding by 2016, said Randy Mayer, chief of the Iowa Bureau of HIV, STD, and Hepatitis.

"We are getting out of the behavioral prevention business," he said in an interview. "We had 16 projects focusing on high-risk negative residents, and we won’t be doing that any more. This is a test, treat, and re-engage model, and it’s a very different way of doing things."

With the new testing-focused model, Iowa risks losing some of its ability to prevent new infections, he said. "We already struggle with late diagnoses, and I worry that this might now be exacerbated."

While some states must wrestle with shrinking programs, others will wrestle with expanding programs. Programs and money usually grow in tandem. States that get this quick cash boost will need time to ramp up programming. Jacquelyn Clymore, director of the North Carolina Department of Health’s Communicable Disease Branch, is face-to-face with this very issue.

"We are one of the fortunate states," she said in an interview. North Carolina, with about 25,000 HIV cases, realized a net increase of $626,000 through the redistribution program. "When you get this money, you also receive the burden of spending it wisely. You need an effective infrastructure, and you don’t put that together overnight. It takes time and community trust. It takes investing in getting trained, sensitive field workers. And you have to do all this right to make sure the money is reaching the people at highest risk with the most effective interventions, to get the best outcomes."

Although Ms. Clymore is thrilled with the "desperately needed" funding increase, she said low-incidence states could suffer the double hit of losing money and then seeing cases increase.

"We had that exact scenario with syphilis here," she said. "We had the highest syphilis rate in the country, and CDC poured money into an effort that brought it down radically. Then we lost that money and syphilis rates rose again. When you take your eye off the ball, it tends to bounce back up."

For more information on the program, visit http://www.cdc.gov/hiv/topics/funding/PS12-1201/.

A major shift in the way the federal government funds state HIV programs is likely to mean more dollars for HIV testing and treatment at the expense of funds to help prevent the disease from developing in the first place among high-risk populations.

The $339 million funding package – about the same amount as in last year’s total – reallocates federal monies by awarding health department grants based on the number of HIV-infected people living in the locality. That means areas with many cases will gain, but areas with fewer cases are going to lose – and some will lose big, said Dr. Donna Sweet, chair of the American Academy of HIV Medicine’s Board of Regents.

The redistribution may actually penalize areas with successful programs, she said in an interview, because years of prevention services and education have decreased their HIV-positive population.

Courtesy KU Internal Medicine Midtown Clinic

"Part of the National HIV/AIDS Strategy is to go where the epidemic is, and by definition to do that you are shifting money, taking it from areas that are doing a great job. But without that money, these low-incidence places run the risk of losing their edge and swinging back toward becoming high-incidence places," Dr. Sweet said.

Prior funding packages were based on the number of AIDS cases. That scenario doesn’t reflect today’s epidemiology, because antiretroviral drugs have cut down on full-blown AIDS cases. Funding based on diagnosis channels the money more effectively, Dr. Kevin Fenton said in a press statement.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever," said Dr. Fenton, director of the Centers for Disease Control and Prevention’s (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. "This new approach to prevention funding is designed to focus on the places where needs are most urgent, and on the programs that will have the most far-reaching impact. It will help us achieve the ambitious goals of the National HIV/AIDS Strategy with the efficiency and urgency the HIV epidemic demands."

Most of the federal money is for increased HIV testing and to link HIV-positive patients to medical care, according to the CDC. The new program will be phased-in over 5 years, with most of this year’s money already promised. A small portion – $20 million – will be awarded this spring to jurisdictions that institute "unique, promising demonstration projects," but standard programs aren’t eligible for that money.

"This new shift in funding to high-impact jurisdictions is leaving lower-impact areas with less," said Murray Penner, deputy director of the National Alliance of State and Territorial AIDS Directors.

"It concerns us that these programs are getting cut. We don’t know what the impact will be. Will it be like the syphilis issue, when we put money into it and it declined, only to reappear when the financial focus went away?"

The group is still calculating the new program’s state-by-state impact. But two states, Hawaii and Iowa, have been particularly hard hit, he said. Both have a low incidence of HIV-infected residents, with about 1,000 new cases each year in Hawaii and just a few hundred in Iowa. But both also have had strong prevention programs for high-risk HIV-negative residents, programs that will now disappear.

Hawaii will endure a 50% federal funding cut by 2016, at which point the new allocation program is expected to be fully implemented. The drop doesn’t account for staff wage increases, lab fees, and transportation costs – a big-ticket item in a multi-island state, said Peter Whiticar, chief of the state’s STD/AIDS Prevention Branch.

The new priority on testing and treatment means that Hawaii and other states must change their HIV focus from behavioral interventions for high-risk HIV-negative clients to medical interventions for the HIV-positive. Although both strategies are key weapons in the HIV fight, health departments may now be forced to focus on one to the detriment of the other. "We simply will not be doing any more behavioral interventions" for HIV-negative at-risk clients, Mr. Whiticar said.

And the federal grant money isn’t just for HIV/AIDS, he pointed out. It also covers services for STD and hepatitis A – an integration that CDC pushed for in the past. This made sense, because the same risky behaviors increase the chance of all these illnesses, and the strategy helped a diverse group of people, Mr. Whiticar said. But because the majority of HIV patients are men, the new funding shift cuts sexual health services for women and transgendered people, he added.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever."

"When you get this kind of funding emphasis on single service, the others start to fall by the wayside. Where the rubber hits the road is that small-incidence states still need to provide the same kind of services as high-incidence states."

Iowa is in a similar situation. The state will lose 55% of its government HIV funding by 2016, said Randy Mayer, chief of the Iowa Bureau of HIV, STD, and Hepatitis.

"We are getting out of the behavioral prevention business," he said in an interview. "We had 16 projects focusing on high-risk negative residents, and we won’t be doing that any more. This is a test, treat, and re-engage model, and it’s a very different way of doing things."

With the new testing-focused model, Iowa risks losing some of its ability to prevent new infections, he said. "We already struggle with late diagnoses, and I worry that this might now be exacerbated."

While some states must wrestle with shrinking programs, others will wrestle with expanding programs. Programs and money usually grow in tandem. States that get this quick cash boost will need time to ramp up programming. Jacquelyn Clymore, director of the North Carolina Department of Health’s Communicable Disease Branch, is face-to-face with this very issue.

"We are one of the fortunate states," she said in an interview. North Carolina, with about 25,000 HIV cases, realized a net increase of $626,000 through the redistribution program. "When you get this money, you also receive the burden of spending it wisely. You need an effective infrastructure, and you don’t put that together overnight. It takes time and community trust. It takes investing in getting trained, sensitive field workers. And you have to do all this right to make sure the money is reaching the people at highest risk with the most effective interventions, to get the best outcomes."

Although Ms. Clymore is thrilled with the "desperately needed" funding increase, she said low-incidence states could suffer the double hit of losing money and then seeing cases increase.

"We had that exact scenario with syphilis here," she said. "We had the highest syphilis rate in the country, and CDC poured money into an effort that brought it down radically. Then we lost that money and syphilis rates rose again. When you take your eye off the ball, it tends to bounce back up."

For more information on the program, visit http://www.cdc.gov/hiv/topics/funding/PS12-1201/.

A major shift in the way the federal government funds state HIV programs is likely to mean more dollars for HIV testing and treatment at the expense of funds to help prevent the disease from developing in the first place among high-risk populations.

The $339 million funding package – about the same amount as in last year’s total – reallocates federal monies by awarding health department grants based on the number of HIV-infected people living in the locality. That means areas with many cases will gain, but areas with fewer cases are going to lose – and some will lose big, said Dr. Donna Sweet, chair of the American Academy of HIV Medicine’s Board of Regents.

The redistribution may actually penalize areas with successful programs, she said in an interview, because years of prevention services and education have decreased their HIV-positive population.

Courtesy KU Internal Medicine Midtown Clinic

"Part of the National HIV/AIDS Strategy is to go where the epidemic is, and by definition to do that you are shifting money, taking it from areas that are doing a great job. But without that money, these low-incidence places run the risk of losing their edge and swinging back toward becoming high-incidence places," Dr. Sweet said.

Prior funding packages were based on the number of AIDS cases. That scenario doesn’t reflect today’s epidemiology, because antiretroviral drugs have cut down on full-blown AIDS cases. Funding based on diagnosis channels the money more effectively, Dr. Kevin Fenton said in a press statement.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever," said Dr. Fenton, director of the Centers for Disease Control and Prevention’s (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. "This new approach to prevention funding is designed to focus on the places where needs are most urgent, and on the programs that will have the most far-reaching impact. It will help us achieve the ambitious goals of the National HIV/AIDS Strategy with the efficiency and urgency the HIV epidemic demands."

Most of the federal money is for increased HIV testing and to link HIV-positive patients to medical care, according to the CDC. The new program will be phased-in over 5 years, with most of this year’s money already promised. A small portion – $20 million – will be awarded this spring to jurisdictions that institute "unique, promising demonstration projects," but standard programs aren’t eligible for that money.

"This new shift in funding to high-impact jurisdictions is leaving lower-impact areas with less," said Murray Penner, deputy director of the National Alliance of State and Territorial AIDS Directors.

"It concerns us that these programs are getting cut. We don’t know what the impact will be. Will it be like the syphilis issue, when we put money into it and it declined, only to reappear when the financial focus went away?"

The group is still calculating the new program’s state-by-state impact. But two states, Hawaii and Iowa, have been particularly hard hit, he said. Both have a low incidence of HIV-infected residents, with about 1,000 new cases each year in Hawaii and just a few hundred in Iowa. But both also have had strong prevention programs for high-risk HIV-negative residents, programs that will now disappear.

Hawaii will endure a 50% federal funding cut by 2016, at which point the new allocation program is expected to be fully implemented. The drop doesn’t account for staff wage increases, lab fees, and transportation costs – a big-ticket item in a multi-island state, said Peter Whiticar, chief of the state’s STD/AIDS Prevention Branch.

The new priority on testing and treatment means that Hawaii and other states must change their HIV focus from behavioral interventions for high-risk HIV-negative clients to medical interventions for the HIV-positive. Although both strategies are key weapons in the HIV fight, health departments may now be forced to focus on one to the detriment of the other. "We simply will not be doing any more behavioral interventions" for HIV-negative at-risk clients, Mr. Whiticar said.

And the federal grant money isn’t just for HIV/AIDS, he pointed out. It also covers services for STD and hepatitis A – an integration that CDC pushed for in the past. This made sense, because the same risky behaviors increase the chance of all these illnesses, and the strategy helped a diverse group of people, Mr. Whiticar said. But because the majority of HIV patients are men, the new funding shift cuts sexual health services for women and transgendered people, he added.

"With 50,000 new HIV infections every year and a tough economic environment, the need to do more with existing resources is greater than ever."

"When you get this kind of funding emphasis on single service, the others start to fall by the wayside. Where the rubber hits the road is that small-incidence states still need to provide the same kind of services as high-incidence states."

Iowa is in a similar situation. The state will lose 55% of its government HIV funding by 2016, said Randy Mayer, chief of the Iowa Bureau of HIV, STD, and Hepatitis.

"We are getting out of the behavioral prevention business," he said in an interview. "We had 16 projects focusing on high-risk negative residents, and we won’t be doing that any more. This is a test, treat, and re-engage model, and it’s a very different way of doing things."

With the new testing-focused model, Iowa risks losing some of its ability to prevent new infections, he said. "We already struggle with late diagnoses, and I worry that this might now be exacerbated."

While some states must wrestle with shrinking programs, others will wrestle with expanding programs. Programs and money usually grow in tandem. States that get this quick cash boost will need time to ramp up programming. Jacquelyn Clymore, director of the North Carolina Department of Health’s Communicable Disease Branch, is face-to-face with this very issue.

"We are one of the fortunate states," she said in an interview. North Carolina, with about 25,000 HIV cases, realized a net increase of $626,000 through the redistribution program. "When you get this money, you also receive the burden of spending it wisely. You need an effective infrastructure, and you don’t put that together overnight. It takes time and community trust. It takes investing in getting trained, sensitive field workers. And you have to do all this right to make sure the money is reaching the people at highest risk with the most effective interventions, to get the best outcomes."

Although Ms. Clymore is thrilled with the "desperately needed" funding increase, she said low-incidence states could suffer the double hit of losing money and then seeing cases increase.

"We had that exact scenario with syphilis here," she said. "We had the highest syphilis rate in the country, and CDC poured money into an effort that brought it down radically. Then we lost that money and syphilis rates rose again. When you take your eye off the ball, it tends to bounce back up."

For more information on the program, visit http://www.cdc.gov/hiv/topics/funding/PS12-1201/.

An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.

Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.

The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.

"Even if the local anesthetic goes away, its beneficial effect does not."

"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."

Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."

Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.

A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."

Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.

In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.

In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."

Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.

"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."

Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.

"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."

Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.

"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."

He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.

An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.

Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.

The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.

"Even if the local anesthetic goes away, its beneficial effect does not."

"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."

Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."

Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.

A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."

Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.

In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.

In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."

Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.

"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."

Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.

"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."

Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.

"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."

He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.

An hour of intravenous anesthetic during surgery can shave a day off the hospital stay and decrease the risk of postoperative complications for some patients, according to Dr. Marcel Durieux.

Intravenous anesthetics (for example, lidocaine) exert surprising effects on recovery from some – but not all – major abdominal surgeries. They’re associated with decreased postoperative pain, quicker return of bowel function, and a shorter length of stay. But they don’t help in all surgeries – not even in all abdominal surgeries – and the way they work is still something of a mystery, he said.

The well-documented systemic benefits of surgical epidurals got anesthesiologists thinking about intravenous agents, said Dr. Durieux, professor of anesthesiology at the University of Virginia, Charlottesville. Epidurals provide excellent postoperative pain control, but it was obvious that their effects spread much farther.

"Even if the local anesthetic goes away, its beneficial effect does not."

"They do much more than just help pain," he said in an interview. "They have significant effects on surgical outcomes that can’t be explained simply by blocking sodium channels in nerves."

Because the effects span several systems, they are probably due to systemic absorption of the anesthetic agent, he said. "If improved outcomes have little to do with blocking nerves, there is no special reason to give an anesthetic near those nerves. You should be able to give it intravenously at doses that lead to blood levels similar to what we get with an epidural."

Researchers have been looking at the issue for more than a decade, and are now honing in on inflammation as the root of these postoperative problems.

A hyperinflammatory response to surgical trauma is probably the root of many postoperative problems, including pain and thrombosis, Dr. Durieux said. "The response develops during the case and lasts into the postoperative period. If it continues, it can lead to a lot of negative effects – increased cardiac strain, impaired respiratory function that can lead to respiratory distress syndrome, nausea and ileus, and a procoagulatory state."

Intravenous local anesthetics seem to suppress that response before it explodes. The drugs likely target neutrophils and the two pathways in which they respond to a bodily injury: priming and activation.

In normal activation, a neutrophil senses bacteria and generates superoxide that kills the invader, leading to the normal inflammatory response seen with an illness. But a wound, including a surgical wound, primes the neutrophils for a superresponse. "Subsequently, when they encounter bacteria, they generate 10 times the amount of superoxide, actually damaging the body," Dr. Durieux said.

In some yet-unknown way, local anesthetics appear to inhibit neutrophilic priming. "There is no other drug around that selectively blocks priming. And if you don’t prime these neutrophils during surgery, you won’t have them there 2 days after surgery causing problems. Even if the local anesthetic goes away, its beneficial effect does not."

Recognition of this prolonged anti-inflammatory effect may eventually shape the administration of intraoperative local anesthetics. Because there is no data-driven protocol, some anesthesiologists give the drug for an hour during surgery, some continue it in the recovery room, and a few want to continue it on the surgical floor.

"This is still a matter of debate. Most of the data show that the vast majority of the benefit can be achieved by giving the drug just for the duration of the case. You can leave it on in the recovery room and turn it off when the patient is ready to go to the floor."

Unfortunately, the agents seem rather selective in their benefit. A 2010 meta-analysis found it most effective in open and laparoscopic bowel surgeries, but unhelpful in small studies on tonsillectomy, arthroscopic surgery, or coronary artery bypass. Another 2010 study found the drugs didn’t have much effect in abdominal hysterectomy, but a 1998 study found it had good effect in prostatectomy.

"I can’t explain that," Dr. Durieux said. "I’m impressed by the data we have but frustrated that the benefit has been shown in just a subset of surgeries."

Although more research is necessary – and in the offing – the drugs are cheap, safe, and easy to use.

"But I’m selective in how I use it. If someone is having an open colectomy and faces prolonged painful ileus, I would consider it, for example. And for people who can’t or won’t accept an epidural, I think this is a reasonable way to go."

He disclosed that he serves on the steering committee of a clinical trial investigating a novel system for delivering local anesthetics to surgical wounds for postoperative pain relief.

Deep-brain stimulation with a constant-current implant significantly boosted "on" time in patients with Parkinson’s disease, with an increase of almost 3 hours more than a group of control patients who had inactive brain implants.

The control group experienced a small improvement immediately after device implantation but a significantly greater one by 3 months after activation – a sign that stimulation, not microlesional effects, mostly likely caused the biggest benefit, according to Dr. Michael S. Okun and his colleagues (Lancet Neurol. 2012;11:140-9).

Most often, deep brain stimulation is administered with a voltage-controlled device with variable current.

"Constant-current devices, such as the one used in this study, have theoretical advantages over voltage-driven devices in that the field of stimulation within brain tissue should be stable in size, whereas stimulation fields produced by voltage-driven devices are susceptible to changes in size caused by changing tissue impedance," wrote Dr. Okun, codirector of the University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, and his associates.

The study randomized 101 patients to immediate activation of a constant-current deep brain stimulation device and 35 to delayed activation. The patients were a mean of 60 years old; mean disease duration was 12 years. They had a mean of 7 hours of good-quality on-medication time at baseline.

All received the Libra DBS device, a constant-current subthalamic nucleus stimulator. The study was not blinded – both patients and physicians knew who would receive immediate and delayed stimulation.

The primary endpoint was the change in good-quality "on" time – that is, free from bothersome dyskinesias. Secondary endpoints included changes in Unified Parkinson’s Disease Rating Scale (UPDRS) scores, quality of life and sleep, medication dosage, and depression.

Patients who underwent active stimulation at the beginning of the trial were assessed at 3, 6, and 12 months. Control patients were assessed at 3 months, after which their stimulation was switched on and they were also assessed at 6 and 12 months. Thus, the active group had 12 months of stimulation time and the control group had 9 months.

At 3 months, both groups reported an increase in good-quality on time. The active group’s response was significantly better, however, increasing by a mean of 4.27 hours (from 7 to 11 hours), compared with 1.77 hours in the control group (from 7 to 9 hours), Dr. Okun and his colleagues reported.

The responder rate (at least a 2-hour improvement from baseline) was 72% in the active group and 38% in the control group – a significant difference. The active group also experienced a significant improvement in the UPDRS motor subscore, compared with the control group. At 3 months, however, there were no significant between-group differences in the UPDRS scores on mentation and activities of daily living.

Verbal fluency scores worsened similarly in both groups 3 months after device activation. "These results indicate that verbal fluency deficits, the most frequent cognitive side-effect after DBS of the subthalamic nucleus, are probably secondary to surgical implantation," the authors wrote.

Both groups experienced a significant decrease in the scale’s L-dopa therapy complications subscore, but the active group had a significantly better score than the control group. The same decline was seen in L-dopa equivalent dosing in both groups. Although both groups had significant declines in L-dopa equivalent dosing compared with baseline, the active group fared significantly better than the control group.

The investigators assessed the groups separately after the control group’s stimulation began at 3 months. By the 6-month visit, the active group’s good-quality on time remained stable. After 3 months of active treatment, the control group’s on time had increased to a extent similar to the treatment group.

At 12 months after the start of the trial, the on time remained steady in the active group and was matched by the control group. The L-dopa equivalent dose also declined similarly in both groups, Dr. Okun and his associates said.

Both groups showed significant improvements in depression over the year. A recent study found the same device to be an effective therapy for treatment-resistant major depression.

Verbal fluency stabilized in both groups after 3 months of treatment but did not improve.

In the active group, there were 20 adverse events among 14 patients. In the control group, there were seven among four patients. The events correlated with the timing of stimulation. Dysarthria, fatigue, falls, postoperative pain and discomfort, and edema were significantly more common in the active group than in the control group.

"These findings have great clinical relevance to clinicians and to patients, who should be aware that programming the DBS device might have unanticipated effects, despite substantial improvement of other motor symptoms and overall increases in on time and quality of life," the investigators wrote.

The study was sponsored by the neuromodulation division of St. Jude Medical Inc. All of the authors reported numerous financial disclosures, including six who are paid consultants for St. Jude Medical.

Deep-brain stimulation with a constant-current implant significantly boosted "on" time in patients with Parkinson’s disease, with an increase of almost 3 hours more than a group of control patients who had inactive brain implants.

The control group experienced a small improvement immediately after device implantation but a significantly greater one by 3 months after activation – a sign that stimulation, not microlesional effects, mostly likely caused the biggest benefit, according to Dr. Michael S. Okun and his colleagues (Lancet Neurol. 2012;11:140-9).

Most often, deep brain stimulation is administered with a voltage-controlled device with variable current.

"Constant-current devices, such as the one used in this study, have theoretical advantages over voltage-driven devices in that the field of stimulation within brain tissue should be stable in size, whereas stimulation fields produced by voltage-driven devices are susceptible to changes in size caused by changing tissue impedance," wrote Dr. Okun, codirector of the University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, and his associates.

The study randomized 101 patients to immediate activation of a constant-current deep brain stimulation device and 35 to delayed activation. The patients were a mean of 60 years old; mean disease duration was 12 years. They had a mean of 7 hours of good-quality on-medication time at baseline.

All received the Libra DBS device, a constant-current subthalamic nucleus stimulator. The study was not blinded – both patients and physicians knew who would receive immediate and delayed stimulation.

The primary endpoint was the change in good-quality "on" time – that is, free from bothersome dyskinesias. Secondary endpoints included changes in Unified Parkinson’s Disease Rating Scale (UPDRS) scores, quality of life and sleep, medication dosage, and depression.

Patients who underwent active stimulation at the beginning of the trial were assessed at 3, 6, and 12 months. Control patients were assessed at 3 months, after which their stimulation was switched on and they were also assessed at 6 and 12 months. Thus, the active group had 12 months of stimulation time and the control group had 9 months.

At 3 months, both groups reported an increase in good-quality on time. The active group’s response was significantly better, however, increasing by a mean of 4.27 hours (from 7 to 11 hours), compared with 1.77 hours in the control group (from 7 to 9 hours), Dr. Okun and his colleagues reported.

The responder rate (at least a 2-hour improvement from baseline) was 72% in the active group and 38% in the control group – a significant difference. The active group also experienced a significant improvement in the UPDRS motor subscore, compared with the control group. At 3 months, however, there were no significant between-group differences in the UPDRS scores on mentation and activities of daily living.

Verbal fluency scores worsened similarly in both groups 3 months after device activation. "These results indicate that verbal fluency deficits, the most frequent cognitive side-effect after DBS of the subthalamic nucleus, are probably secondary to surgical implantation," the authors wrote.

Both groups experienced a significant decrease in the scale’s L-dopa therapy complications subscore, but the active group had a significantly better score than the control group. The same decline was seen in L-dopa equivalent dosing in both groups. Although both groups had significant declines in L-dopa equivalent dosing compared with baseline, the active group fared significantly better than the control group.

The investigators assessed the groups separately after the control group’s stimulation began at 3 months. By the 6-month visit, the active group’s good-quality on time remained stable. After 3 months of active treatment, the control group’s on time had increased to a extent similar to the treatment group.

At 12 months after the start of the trial, the on time remained steady in the active group and was matched by the control group. The L-dopa equivalent dose also declined similarly in both groups, Dr. Okun and his associates said.

Both groups showed significant improvements in depression over the year. A recent study found the same device to be an effective therapy for treatment-resistant major depression.

Verbal fluency stabilized in both groups after 3 months of treatment but did not improve.

In the active group, there were 20 adverse events among 14 patients. In the control group, there were seven among four patients. The events correlated with the timing of stimulation. Dysarthria, fatigue, falls, postoperative pain and discomfort, and edema were significantly more common in the active group than in the control group.

"These findings have great clinical relevance to clinicians and to patients, who should be aware that programming the DBS device might have unanticipated effects, despite substantial improvement of other motor symptoms and overall increases in on time and quality of life," the investigators wrote.

The study was sponsored by the neuromodulation division of St. Jude Medical Inc. All of the authors reported numerous financial disclosures, including six who are paid consultants for St. Jude Medical.

Deep-brain stimulation with a constant-current implant significantly boosted "on" time in patients with Parkinson’s disease, with an increase of almost 3 hours more than a group of control patients who had inactive brain implants.

The control group experienced a small improvement immediately after device implantation but a significantly greater one by 3 months after activation – a sign that stimulation, not microlesional effects, mostly likely caused the biggest benefit, according to Dr. Michael S. Okun and his colleagues (Lancet Neurol. 2012;11:140-9).

Most often, deep brain stimulation is administered with a voltage-controlled device with variable current.

"Constant-current devices, such as the one used in this study, have theoretical advantages over voltage-driven devices in that the field of stimulation within brain tissue should be stable in size, whereas stimulation fields produced by voltage-driven devices are susceptible to changes in size caused by changing tissue impedance," wrote Dr. Okun, codirector of the University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, and his associates.

The study randomized 101 patients to immediate activation of a constant-current deep brain stimulation device and 35 to delayed activation. The patients were a mean of 60 years old; mean disease duration was 12 years. They had a mean of 7 hours of good-quality on-medication time at baseline.

All received the Libra DBS device, a constant-current subthalamic nucleus stimulator. The study was not blinded – both patients and physicians knew who would receive immediate and delayed stimulation.

The primary endpoint was the change in good-quality "on" time – that is, free from bothersome dyskinesias. Secondary endpoints included changes in Unified Parkinson’s Disease Rating Scale (UPDRS) scores, quality of life and sleep, medication dosage, and depression.

Patients who underwent active stimulation at the beginning of the trial were assessed at 3, 6, and 12 months. Control patients were assessed at 3 months, after which their stimulation was switched on and they were also assessed at 6 and 12 months. Thus, the active group had 12 months of stimulation time and the control group had 9 months.

At 3 months, both groups reported an increase in good-quality on time. The active group’s response was significantly better, however, increasing by a mean of 4.27 hours (from 7 to 11 hours), compared with 1.77 hours in the control group (from 7 to 9 hours), Dr. Okun and his colleagues reported.

The responder rate (at least a 2-hour improvement from baseline) was 72% in the active group and 38% in the control group – a significant difference. The active group also experienced a significant improvement in the UPDRS motor subscore, compared with the control group. At 3 months, however, there were no significant between-group differences in the UPDRS scores on mentation and activities of daily living.

Verbal fluency scores worsened similarly in both groups 3 months after device activation. "These results indicate that verbal fluency deficits, the most frequent cognitive side-effect after DBS of the subthalamic nucleus, are probably secondary to surgical implantation," the authors wrote.

Both groups experienced a significant decrease in the scale’s L-dopa therapy complications subscore, but the active group had a significantly better score than the control group. The same decline was seen in L-dopa equivalent dosing in both groups. Although both groups had significant declines in L-dopa equivalent dosing compared with baseline, the active group fared significantly better than the control group.

The investigators assessed the groups separately after the control group’s stimulation began at 3 months. By the 6-month visit, the active group’s good-quality on time remained stable. After 3 months of active treatment, the control group’s on time had increased to a extent similar to the treatment group.

At 12 months after the start of the trial, the on time remained steady in the active group and was matched by the control group. The L-dopa equivalent dose also declined similarly in both groups, Dr. Okun and his associates said.

Both groups showed significant improvements in depression over the year. A recent study found the same device to be an effective therapy for treatment-resistant major depression.

Verbal fluency stabilized in both groups after 3 months of treatment but did not improve.

In the active group, there were 20 adverse events among 14 patients. In the control group, there were seven among four patients. The events correlated with the timing of stimulation. Dysarthria, fatigue, falls, postoperative pain and discomfort, and edema were significantly more common in the active group than in the control group.

"These findings have great clinical relevance to clinicians and to patients, who should be aware that programming the DBS device might have unanticipated effects, despite substantial improvement of other motor symptoms and overall increases in on time and quality of life," the investigators wrote.

The study was sponsored by the neuromodulation division of St. Jude Medical Inc. All of the authors reported numerous financial disclosures, including six who are paid consultants for St. Jude Medical.

Binge drinking appears to be more common in the United States than previously thought, with about 17% of adults aged 18 years and over engaging in the behavior each month.

About 38 million U.S. adults went on at least one drinking binge in 2010, according to a new federal report. Unfortunately, that number probably represents less than a third of the actual binge drinking that goes on, according to Dr. Robert Brewer of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPH).

"We know that surveys like this one pick up only about 33% of presumed alcohol consumption, based on per capita sales," he said in a press briefing. Bingeing accounts for half of the country’s alcohol consumption overall, he noted, and up to 90% of that consumed by young people.

© Nikada/iStockphoto.com

The 2010 Behavioral Risk Factor Surveillance System (BRFSS) found bingeing in virtually every state and in every population group, regardless of age, ethnicity, race, and socioeconomic level. Even states with a comparatively lower prevalence showed serious bingeing problems, Dr. Brewer said. "We found a number of states with a low prevalence but a very high frequency or number of drinks per episode. We can’t be lulled into a false sense of security. There are high-risk drinkers in every population, even though it might not look like a big problem," he said.

The data were compiled through the 2010 BRFSS, an annual nationwide telephone survey. The survey included responses from almost 458,000 civilian U.S. adults in 48 states and the District of Columbia. (South Dakota and Tennessee were not included.) For the first time, cell phone users were included. Binge drinking was defined as four or more drinks for women and five or more drinks for men on one occasion during the past 30 days.

"Physicians need to adopt these numbers – five drinks or more on any occasion for a man and four drinks or more for a woman is unhealthy, unwise, and dangerous," Dr. Robert L. DuPont, the first director of the National Institute on Drug Abuse, said in an interview when asked about the survey. "There is no other step that can match the power of the nation’s physicians once they make this question a routine part of every patient contact."

Overall, bingeing prevalence was up 2% from 2009, but that increase probably is attributable to the inclusion of cell phone users, Dafna Kanny, Ph.D., wrote in the Jan. 10 issue of Morbidity and Mortality Weekly Report (2012;61:1-7).

"Cellular telephone–only users typically are young (aged 18-34 years) and male; both groups tend to report a higher prevalence of binge drinking," wrote Dr. Kanny, also of the NCCDPH.

No group was exempt from the problem, the report found. Men were more likely to binge than women (23.2% vs. 11.4%). Overall, bingeing was most common among those aged 18-34 years (28.2%). But the oldest respondents, those aged 65 years and older, binged the most often, at 5.5 times per month.

Non-Hispanic whites (18%) and Hispanics (17.9%) were significantly more likely to binge than blacks (12.7%).

Education also influenced bingeing. Those who did not graduate from high school had the lowest prevalence (13.7%), but drank more frequently and intensely than those of other educational levels (5.5 times per month with 9.3 drinks per episode).

Respondents with the highest incomes ($75,000 or more) were more likely to binge (20.2%), but those with the lowest incomes ($25,000 or less) drank more frequently and more intensely (5 times per month and 8.5 drinks per episode).

Bingeing also varied by state. Utah had the lowest age-adjusted prevalence (10.9%) and Wisconsin the highest (25.6%) Wisconsin residents also drank the most per episode (9). Bingers drank least often in New Jersey and most often in Kentucky (3.6 vs. 5.9 times per month).

Demographic differences in binge drinking are likely related to laws that affect the price and availability of alcohol, the authors noted. Studies have shows that a 10% price increase can decrease alcohol consumption by 7% in a population.

The Community Preventive Services Task Force has made several recommendations designed to change these factors, including:

• Limiting the density of stores that sell alcohol.

• Holding retailers accountable for harms resulting from sales to minors and already intoxicated persons.

• Maintaining existing limits on times and days of sale.

• Price increases.

• Avoiding further privatization of sales outlets.

"There are high-risk drinkers in every population, even though it might not look like a big problem."

From 2001 to 2005, excessive alcohol use accounted for an estimated average of 80,000 deaths and 2.3 million years of potential life lost in the United States, the report noted. Binge drinking accounted for more than half of the deaths, two-thirds of the life/years lost, and three-quarters of the economic costs.

Bingeing also significantly contributes to the incidence of other risky behaviors, like interpersonal violence, unsafe sex, and impaired driving, Dr. Brewer said. "As the number of drinks increases over a short period of time, the risk of these adverse outcomes goes up. Clearly, we have a lot of work to do to bring down the frequency and intensity of binge drinking."

He also stressed that many binge drinkers don’t meet the medical criteria for alcohol dependence. "You don’t have to be alcohol dependent to experience a whole host of alcohol-related problems. If a person is consuming eight drinks in a short period of time, they are putting themselves and others at a great risk of alcohol-related harm."

As government employees, Dr. Brewer and Dr. Kanny had no financial conflicts.

Binge drinking appears to be more common in the United States than previously thought, with about 17% of adults aged 18 years and over engaging in the behavior each month.

About 38 million U.S. adults went on at least one drinking binge in 2010, according to a new federal report. Unfortunately, that number probably represents less than a third of the actual binge drinking that goes on, according to Dr. Robert Brewer of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPH).

"We know that surveys like this one pick up only about 33% of presumed alcohol consumption, based on per capita sales," he said in a press briefing. Bingeing accounts for half of the country’s alcohol consumption overall, he noted, and up to 90% of that consumed by young people.

© Nikada/iStockphoto.com

The 2010 Behavioral Risk Factor Surveillance System (BRFSS) found bingeing in virtually every state and in every population group, regardless of age, ethnicity, race, and socioeconomic level. Even states with a comparatively lower prevalence showed serious bingeing problems, Dr. Brewer said. "We found a number of states with a low prevalence but a very high frequency or number of drinks per episode. We can’t be lulled into a false sense of security. There are high-risk drinkers in every population, even though it might not look like a big problem," he said.

The data were compiled through the 2010 BRFSS, an annual nationwide telephone survey. The survey included responses from almost 458,000 civilian U.S. adults in 48 states and the District of Columbia. (South Dakota and Tennessee were not included.) For the first time, cell phone users were included. Binge drinking was defined as four or more drinks for women and five or more drinks for men on one occasion during the past 30 days.

"Physicians need to adopt these numbers – five drinks or more on any occasion for a man and four drinks or more for a woman is unhealthy, unwise, and dangerous," Dr. Robert L. DuPont, the first director of the National Institute on Drug Abuse, said in an interview when asked about the survey. "There is no other step that can match the power of the nation’s physicians once they make this question a routine part of every patient contact."

Overall, bingeing prevalence was up 2% from 2009, but that increase probably is attributable to the inclusion of cell phone users, Dafna Kanny, Ph.D., wrote in the Jan. 10 issue of Morbidity and Mortality Weekly Report (2012;61:1-7).

"Cellular telephone–only users typically are young (aged 18-34 years) and male; both groups tend to report a higher prevalence of binge drinking," wrote Dr. Kanny, also of the NCCDPH.

No group was exempt from the problem, the report found. Men were more likely to binge than women (23.2% vs. 11.4%). Overall, bingeing was most common among those aged 18-34 years (28.2%). But the oldest respondents, those aged 65 years and older, binged the most often, at 5.5 times per month.

Non-Hispanic whites (18%) and Hispanics (17.9%) were significantly more likely to binge than blacks (12.7%).

Education also influenced bingeing. Those who did not graduate from high school had the lowest prevalence (13.7%), but drank more frequently and intensely than those of other educational levels (5.5 times per month with 9.3 drinks per episode).

Respondents with the highest incomes ($75,000 or more) were more likely to binge (20.2%), but those with the lowest incomes ($25,000 or less) drank more frequently and more intensely (5 times per month and 8.5 drinks per episode).

Bingeing also varied by state. Utah had the lowest age-adjusted prevalence (10.9%) and Wisconsin the highest (25.6%) Wisconsin residents also drank the most per episode (9). Bingers drank least often in New Jersey and most often in Kentucky (3.6 vs. 5.9 times per month).

Demographic differences in binge drinking are likely related to laws that affect the price and availability of alcohol, the authors noted. Studies have shows that a 10% price increase can decrease alcohol consumption by 7% in a population.

The Community Preventive Services Task Force has made several recommendations designed to change these factors, including:

• Limiting the density of stores that sell alcohol.

• Holding retailers accountable for harms resulting from sales to minors and already intoxicated persons.

• Maintaining existing limits on times and days of sale.

• Price increases.

• Avoiding further privatization of sales outlets.

"There are high-risk drinkers in every population, even though it might not look like a big problem."

From 2001 to 2005, excessive alcohol use accounted for an estimated average of 80,000 deaths and 2.3 million years of potential life lost in the United States, the report noted. Binge drinking accounted for more than half of the deaths, two-thirds of the life/years lost, and three-quarters of the economic costs.

Bingeing also significantly contributes to the incidence of other risky behaviors, like interpersonal violence, unsafe sex, and impaired driving, Dr. Brewer said. "As the number of drinks increases over a short period of time, the risk of these adverse outcomes goes up. Clearly, we have a lot of work to do to bring down the frequency and intensity of binge drinking."

He also stressed that many binge drinkers don’t meet the medical criteria for alcohol dependence. "You don’t have to be alcohol dependent to experience a whole host of alcohol-related problems. If a person is consuming eight drinks in a short period of time, they are putting themselves and others at a great risk of alcohol-related harm."

As government employees, Dr. Brewer and Dr. Kanny had no financial conflicts.

Binge drinking appears to be more common in the United States than previously thought, with about 17% of adults aged 18 years and over engaging in the behavior each month.

About 38 million U.S. adults went on at least one drinking binge in 2010, according to a new federal report. Unfortunately, that number probably represents less than a third of the actual binge drinking that goes on, according to Dr. Robert Brewer of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPH).

"We know that surveys like this one pick up only about 33% of presumed alcohol consumption, based on per capita sales," he said in a press briefing. Bingeing accounts for half of the country’s alcohol consumption overall, he noted, and up to 90% of that consumed by young people.

© Nikada/iStockphoto.com

The 2010 Behavioral Risk Factor Surveillance System (BRFSS) found bingeing in virtually every state and in every population group, regardless of age, ethnicity, race, and socioeconomic level. Even states with a comparatively lower prevalence showed serious bingeing problems, Dr. Brewer said. "We found a number of states with a low prevalence but a very high frequency or number of drinks per episode. We can’t be lulled into a false sense of security. There are high-risk drinkers in every population, even though it might not look like a big problem," he said.

The data were compiled through the 2010 BRFSS, an annual nationwide telephone survey. The survey included responses from almost 458,000 civilian U.S. adults in 48 states and the District of Columbia. (South Dakota and Tennessee were not included.) For the first time, cell phone users were included. Binge drinking was defined as four or more drinks for women and five or more drinks for men on one occasion during the past 30 days.

"Physicians need to adopt these numbers – five drinks or more on any occasion for a man and four drinks or more for a woman is unhealthy, unwise, and dangerous," Dr. Robert L. DuPont, the first director of the National Institute on Drug Abuse, said in an interview when asked about the survey. "There is no other step that can match the power of the nation’s physicians once they make this question a routine part of every patient contact."

Overall, bingeing prevalence was up 2% from 2009, but that increase probably is attributable to the inclusion of cell phone users, Dafna Kanny, Ph.D., wrote in the Jan. 10 issue of Morbidity and Mortality Weekly Report (2012;61:1-7).

"Cellular telephone–only users typically are young (aged 18-34 years) and male; both groups tend to report a higher prevalence of binge drinking," wrote Dr. Kanny, also of the NCCDPH.

No group was exempt from the problem, the report found. Men were more likely to binge than women (23.2% vs. 11.4%). Overall, bingeing was most common among those aged 18-34 years (28.2%). But the oldest respondents, those aged 65 years and older, binged the most often, at 5.5 times per month.

Non-Hispanic whites (18%) and Hispanics (17.9%) were significantly more likely to binge than blacks (12.7%).

Education also influenced bingeing. Those who did not graduate from high school had the lowest prevalence (13.7%), but drank more frequently and intensely than those of other educational levels (5.5 times per month with 9.3 drinks per episode).

Respondents with the highest incomes ($75,000 or more) were more likely to binge (20.2%), but those with the lowest incomes ($25,000 or less) drank more frequently and more intensely (5 times per month and 8.5 drinks per episode).

Bingeing also varied by state. Utah had the lowest age-adjusted prevalence (10.9%) and Wisconsin the highest (25.6%) Wisconsin residents also drank the most per episode (9). Bingers drank least often in New Jersey and most often in Kentucky (3.6 vs. 5.9 times per month).

Demographic differences in binge drinking are likely related to laws that affect the price and availability of alcohol, the authors noted. Studies have shows that a 10% price increase can decrease alcohol consumption by 7% in a population.

The Community Preventive Services Task Force has made several recommendations designed to change these factors, including:

• Limiting the density of stores that sell alcohol.

• Holding retailers accountable for harms resulting from sales to minors and already intoxicated persons.

• Maintaining existing limits on times and days of sale.

• Price increases.

• Avoiding further privatization of sales outlets.

"There are high-risk drinkers in every population, even though it might not look like a big problem."

From 2001 to 2005, excessive alcohol use accounted for an estimated average of 80,000 deaths and 2.3 million years of potential life lost in the United States, the report noted. Binge drinking accounted for more than half of the deaths, two-thirds of the life/years lost, and three-quarters of the economic costs.

Bingeing also significantly contributes to the incidence of other risky behaviors, like interpersonal violence, unsafe sex, and impaired driving, Dr. Brewer said. "As the number of drinks increases over a short period of time, the risk of these adverse outcomes goes up. Clearly, we have a lot of work to do to bring down the frequency and intensity of binge drinking."

He also stressed that many binge drinkers don’t meet the medical criteria for alcohol dependence. "You don’t have to be alcohol dependent to experience a whole host of alcohol-related problems. If a person is consuming eight drinks in a short period of time, they are putting themselves and others at a great risk of alcohol-related harm."

As government employees, Dr. Brewer and Dr. Kanny had no financial conflicts.

Packaging errors in a Novartis drug plant could cause opioid painkillers to end up in bottles of over-the-counter medications, the Food and Drug Administration said today.

Opioid pills could have been retained in the machinery and then released into bottles of other types of prescription painkillers, or into over-the-counter medications including Excedrin, Bufferin, No-Doze, and Gas-X, according to Dr. Edward Cox, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research.

"The likelihood of this happening is low, but there is a potential" for mix-ups, Dr. Cox said during a press briefing. Although there have been no reports of stray opioids in other medications, the possibility of a mix-up is so serious that FDA was compelled to issue a public health advisory. Novartis voluntarily closed its Lincoln, Neb., plant that manufactured and packaged opiate products for Endo Pharmaceuticals after a mid-December inspection focused on packaging machinery.

The same manufacturing problem has damaged gel caps and tablets of the over-the-counter medications; these also could be mispackaged among themselves. Because of the problems, Novartis has issued a nationwide recall of all these brands with an expiration date prior to Dec. 20, 2014.

However, the manufacturing problems at the Lincoln, Neb., plant were not a surprise to the FDA. A 13-page document details the results of several federal inspections undertaken from 2009 to 2011. According to the document, Novartis failed to respond to almost 200 consumer complaints about solid drugs made at the plant, including cases in which Excedrin Migraine gel caps and tablets were packed in the same bottle (this was considered a case of "foreign tablets").

"You have failed to adequately investigate 166 instances of foreign tablets in your drug products since 2009," the report stated.

Dr. Cox said the latest inspection focused on the packaging machinery and was the impetus for the plant’s closing. Endo Pharmaceuticals, the company that uses the plant to manufacture its opioid products, has received three consumer complaints about the issue since 2009, Dr. Cox said.

These medications will be in short supply, at least temporarily, according to a company spokesman. "We really don’t know how long the situation will go on," Chris Clark, associate director of marketing and communications at Endo Pharmaceuticals, said in an interview. "We hope the [shut-down time] will be as minimal as possible."

Mr. Clark said the company is "working proactively" with physicians to conserve the drugs that are still available for patients already taking them. "We’ve issued a health care practitioner letter suggesting that physicians keep patients on their ongoing therapy, but consider limiting starts on new patients, as appropriate."

The affected medications include:

• OPANA (oxymorphone hydrochloride) Extended Release Tablets CII

• OPANA (oxymorphone hydrochloride) Tablets CII

• PERCOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• PERCODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• ENDOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• ENDODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• Morphine sulfate Extended-Release Tablets CII

• ZYDONE (hydrocodone bitartrate/acetaminophen tablets, USP) CIII

Endo Pharmaceuticals has posted picture of the medications in question on its website.

Dr. Cox recommended that both pharmacists and patients be extra-vigilant about any of the medications in question. "Check the medication carefully for tablets that are a different size or color, and take them back to the pharmacy if you find this," he recommended. Pharmacists should carefully inspect medication before dispensing it.

Packaging errors in a Novartis drug plant could cause opioid painkillers to end up in bottles of over-the-counter medications, the Food and Drug Administration said today.

Opioid pills could have been retained in the machinery and then released into bottles of other types of prescription painkillers, or into over-the-counter medications including Excedrin, Bufferin, No-Doze, and Gas-X, according to Dr. Edward Cox, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research.

"The likelihood of this happening is low, but there is a potential" for mix-ups, Dr. Cox said during a press briefing. Although there have been no reports of stray opioids in other medications, the possibility of a mix-up is so serious that FDA was compelled to issue a public health advisory. Novartis voluntarily closed its Lincoln, Neb., plant that manufactured and packaged opiate products for Endo Pharmaceuticals after a mid-December inspection focused on packaging machinery.

The same manufacturing problem has damaged gel caps and tablets of the over-the-counter medications; these also could be mispackaged among themselves. Because of the problems, Novartis has issued a nationwide recall of all these brands with an expiration date prior to Dec. 20, 2014.

However, the manufacturing problems at the Lincoln, Neb., plant were not a surprise to the FDA. A 13-page document details the results of several federal inspections undertaken from 2009 to 2011. According to the document, Novartis failed to respond to almost 200 consumer complaints about solid drugs made at the plant, including cases in which Excedrin Migraine gel caps and tablets were packed in the same bottle (this was considered a case of "foreign tablets").

"You have failed to adequately investigate 166 instances of foreign tablets in your drug products since 2009," the report stated.

Dr. Cox said the latest inspection focused on the packaging machinery and was the impetus for the plant’s closing. Endo Pharmaceuticals, the company that uses the plant to manufacture its opioid products, has received three consumer complaints about the issue since 2009, Dr. Cox said.

These medications will be in short supply, at least temporarily, according to a company spokesman. "We really don’t know how long the situation will go on," Chris Clark, associate director of marketing and communications at Endo Pharmaceuticals, said in an interview. "We hope the [shut-down time] will be as minimal as possible."

Mr. Clark said the company is "working proactively" with physicians to conserve the drugs that are still available for patients already taking them. "We’ve issued a health care practitioner letter suggesting that physicians keep patients on their ongoing therapy, but consider limiting starts on new patients, as appropriate."

The affected medications include:

• OPANA (oxymorphone hydrochloride) Extended Release Tablets CII

• OPANA (oxymorphone hydrochloride) Tablets CII

• PERCOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• PERCODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• ENDOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• ENDODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• Morphine sulfate Extended-Release Tablets CII

• ZYDONE (hydrocodone bitartrate/acetaminophen tablets, USP) CIII

Endo Pharmaceuticals has posted picture of the medications in question on its website.

Dr. Cox recommended that both pharmacists and patients be extra-vigilant about any of the medications in question. "Check the medication carefully for tablets that are a different size or color, and take them back to the pharmacy if you find this," he recommended. Pharmacists should carefully inspect medication before dispensing it.

Packaging errors in a Novartis drug plant could cause opioid painkillers to end up in bottles of over-the-counter medications, the Food and Drug Administration said today.

Opioid pills could have been retained in the machinery and then released into bottles of other types of prescription painkillers, or into over-the-counter medications including Excedrin, Bufferin, No-Doze, and Gas-X, according to Dr. Edward Cox, director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research.

"The likelihood of this happening is low, but there is a potential" for mix-ups, Dr. Cox said during a press briefing. Although there have been no reports of stray opioids in other medications, the possibility of a mix-up is so serious that FDA was compelled to issue a public health advisory. Novartis voluntarily closed its Lincoln, Neb., plant that manufactured and packaged opiate products for Endo Pharmaceuticals after a mid-December inspection focused on packaging machinery.

The same manufacturing problem has damaged gel caps and tablets of the over-the-counter medications; these also could be mispackaged among themselves. Because of the problems, Novartis has issued a nationwide recall of all these brands with an expiration date prior to Dec. 20, 2014.

However, the manufacturing problems at the Lincoln, Neb., plant were not a surprise to the FDA. A 13-page document details the results of several federal inspections undertaken from 2009 to 2011. According to the document, Novartis failed to respond to almost 200 consumer complaints about solid drugs made at the plant, including cases in which Excedrin Migraine gel caps and tablets were packed in the same bottle (this was considered a case of "foreign tablets").

"You have failed to adequately investigate 166 instances of foreign tablets in your drug products since 2009," the report stated.

Dr. Cox said the latest inspection focused on the packaging machinery and was the impetus for the plant’s closing. Endo Pharmaceuticals, the company that uses the plant to manufacture its opioid products, has received three consumer complaints about the issue since 2009, Dr. Cox said.

These medications will be in short supply, at least temporarily, according to a company spokesman. "We really don’t know how long the situation will go on," Chris Clark, associate director of marketing and communications at Endo Pharmaceuticals, said in an interview. "We hope the [shut-down time] will be as minimal as possible."

Mr. Clark said the company is "working proactively" with physicians to conserve the drugs that are still available for patients already taking them. "We’ve issued a health care practitioner letter suggesting that physicians keep patients on their ongoing therapy, but consider limiting starts on new patients, as appropriate."

The affected medications include:

• OPANA (oxymorphone hydrochloride) Extended Release Tablets CII

• OPANA (oxymorphone hydrochloride) Tablets CII

• PERCOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• PERCODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• ENDOCET (oxycodone hydrochloride and acetaminophen USP) Tablets CII

• ENDODAN (oxycodone hydrochloride and aspirin, USP) Tablets CII

• Morphine sulfate Extended-Release Tablets CII

• ZYDONE (hydrocodone bitartrate/acetaminophen tablets, USP) CIII

Endo Pharmaceuticals has posted picture of the medications in question on its website.

Dr. Cox recommended that both pharmacists and patients be extra-vigilant about any of the medications in question. "Check the medication carefully for tablets that are a different size or color, and take them back to the pharmacy if you find this," he recommended. Pharmacists should carefully inspect medication before dispensing it.

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.