Roxanne Nelson

SAN ANTONIO — A new rapidly acting effervescent formulation of fentanyl appears to be safe and effective when used to treat breakthrough pain in cancer patients.

Results of preliminary research show that fentanyl effervescent buccal tablets (FEBT) may provide rapid-onset analgesia in patients with cancer-related breakthrough pain, which is usually treated with a short-acting opioid.

“This formulation is designed to enhance the rate and efficiency of fentanyl absorption through the buccal mucosa,” Dr. Donald Taylor reported at the annual meeting of the American Pain Society.

Dr. Taylor, medical director of a group practice specializing in pain care in Marietta, Ga., and his colleagues evaluated the efficacy and tolerability of FEBT in 123 opioid-tolerant patients with chronic pain associated with cancer, in a double-blind, randomized, placebo-controlled study.

The Sum of Pain Intensity Difference (SPID), an outcome measure that summarizes treatment response, was evaluated during the first 30 minutes as the primary efficacy measure. The researchers also assessed pain at 45 and 60 minutes after delivery of the drug, evaluated patients' self-reported pain relief, and tracked the number of times patients required rescue medication.

Clinically significant decreases in pain intensity (33% or more) were observed in 13% of episodes at 15 minutes and in 48% of episodes by 30 minutes after drug delivery. At all end points, the percentage of episodes showing a decrease in pain intensity greater than 33% was significantly greater with FEBT than with placebo. After 30 minutes, pain intensity decreased by 50% or more with FEBT in 24% of episodes.

“We looked at about 500 breakthrough pain episodes and about half were relieved at 30 minutes, if you consider 'greater than 33%' to be relief,” Dr. Taylor said. In all measurements, the analgesic effect of FEBT exceeded that of placebo.

In summary, FEBT produced a rapid onset of action and was superior to placebo. It was reasonably well tolerated and appears to be a relatively effective treatment for breakthrough pain in patients with cancer, he said.

SAN ANTONIO — A new rapidly acting effervescent formulation of fentanyl appears to be safe and effective when used to treat breakthrough pain in cancer patients.

Results of preliminary research show that fentanyl effervescent buccal tablets (FEBT) may provide rapid-onset analgesia in patients with cancer-related breakthrough pain, which is usually treated with a short-acting opioid.

“This formulation is designed to enhance the rate and efficiency of fentanyl absorption through the buccal mucosa,” Dr. Donald Taylor reported at the annual meeting of the American Pain Society.

Dr. Taylor, medical director of a group practice specializing in pain care in Marietta, Ga., and his colleagues evaluated the efficacy and tolerability of FEBT in 123 opioid-tolerant patients with chronic pain associated with cancer, in a double-blind, randomized, placebo-controlled study.

The Sum of Pain Intensity Difference (SPID), an outcome measure that summarizes treatment response, was evaluated during the first 30 minutes as the primary efficacy measure. The researchers also assessed pain at 45 and 60 minutes after delivery of the drug, evaluated patients' self-reported pain relief, and tracked the number of times patients required rescue medication.

Clinically significant decreases in pain intensity (33% or more) were observed in 13% of episodes at 15 minutes and in 48% of episodes by 30 minutes after drug delivery. At all end points, the percentage of episodes showing a decrease in pain intensity greater than 33% was significantly greater with FEBT than with placebo. After 30 minutes, pain intensity decreased by 50% or more with FEBT in 24% of episodes.

“We looked at about 500 breakthrough pain episodes and about half were relieved at 30 minutes, if you consider 'greater than 33%' to be relief,” Dr. Taylor said. In all measurements, the analgesic effect of FEBT exceeded that of placebo.

In summary, FEBT produced a rapid onset of action and was superior to placebo. It was reasonably well tolerated and appears to be a relatively effective treatment for breakthrough pain in patients with cancer, he said.

SAN ANTONIO — A new rapidly acting effervescent formulation of fentanyl appears to be safe and effective when used to treat breakthrough pain in cancer patients.

Results of preliminary research show that fentanyl effervescent buccal tablets (FEBT) may provide rapid-onset analgesia in patients with cancer-related breakthrough pain, which is usually treated with a short-acting opioid.

“This formulation is designed to enhance the rate and efficiency of fentanyl absorption through the buccal mucosa,” Dr. Donald Taylor reported at the annual meeting of the American Pain Society.

Dr. Taylor, medical director of a group practice specializing in pain care in Marietta, Ga., and his colleagues evaluated the efficacy and tolerability of FEBT in 123 opioid-tolerant patients with chronic pain associated with cancer, in a double-blind, randomized, placebo-controlled study.

The Sum of Pain Intensity Difference (SPID), an outcome measure that summarizes treatment response, was evaluated during the first 30 minutes as the primary efficacy measure. The researchers also assessed pain at 45 and 60 minutes after delivery of the drug, evaluated patients' self-reported pain relief, and tracked the number of times patients required rescue medication.

Clinically significant decreases in pain intensity (33% or more) were observed in 13% of episodes at 15 minutes and in 48% of episodes by 30 minutes after drug delivery. At all end points, the percentage of episodes showing a decrease in pain intensity greater than 33% was significantly greater with FEBT than with placebo. After 30 minutes, pain intensity decreased by 50% or more with FEBT in 24% of episodes.

“We looked at about 500 breakthrough pain episodes and about half were relieved at 30 minutes, if you consider 'greater than 33%' to be relief,” Dr. Taylor said. In all measurements, the analgesic effect of FEBT exceeded that of placebo.

In summary, FEBT produced a rapid onset of action and was superior to placebo. It was reasonably well tolerated and appears to be a relatively effective treatment for breakthrough pain in patients with cancer, he said.

BOCA RATON, FLA. — A new light-emitting diode device awaiting approval and an expected expanded indication for a laser are poised to expand the dermatologic device armamentarium, Dr. Vic Narurkar said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"One of the most exciting technologies to come out this year is a dermal spectrophotometer, because it will be a way of determining the skin's erythema and melanin content," said Dr. Narurkar, a dermatologist in private practice in San Francisco.

This advance is needed because the Fitzgerald skin type classification is outdated, he explained. "Darker skin often gets lumped into the Fitzpatrick IV, V, and VI, when there are many variations within all of those skin types," he said.

A far better method is to have some type of computer model determine the pigmentation and redness, as well as the background pigmentation and redness.

Another reason for improving the current classification system is that coloring on the face and body may not match.

This LED device, manufactured by Palomar Medical Technologies Inc., is pending approval. The hope is that it will be released by summer's end, he said.

Photopneumatic laser therapy, another new device, manufactured by Aesthera Corp., has been cleared by the FDA for hair removal and skin rejuvenation. However, it is being used off label to treat acne and is in clinical trials for that indication.

The theory behind this device is very intriguing, in that is uses suction and lower wavelengths of light, explained Dr. Narurkar. "When we treat acne with lasers, we either try to destroy the Propionibacterium acnes bacteria with devices that are in the blue light wavelength, or we try to modify the sebaceous glands with devices that are in the red light wavelength," he said. A suction-based device can be brought closer to the skin and simultaneously is able to address both the P. acnes bacteria and the sebaceous glands. The photopneumatic laser uses a lower band of light, which allows for better absorption.

"In our clinical study, we saw an immediate improvement in the inflammatory component of acne, and then more of a delayed effect in the reduction of new acne lesions," Dr. Narurkar explained. "The device is in clinical trials right now."

Dr. Narurkar is a member of the medical advisory board of Aesthera, and he performs clinical studies for Palomar Medical Technologies.

BOCA RATON, FLA. — A new light-emitting diode device awaiting approval and an expected expanded indication for a laser are poised to expand the dermatologic device armamentarium, Dr. Vic Narurkar said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"One of the most exciting technologies to come out this year is a dermal spectrophotometer, because it will be a way of determining the skin's erythema and melanin content," said Dr. Narurkar, a dermatologist in private practice in San Francisco.

This advance is needed because the Fitzgerald skin type classification is outdated, he explained. "Darker skin often gets lumped into the Fitzpatrick IV, V, and VI, when there are many variations within all of those skin types," he said.

A far better method is to have some type of computer model determine the pigmentation and redness, as well as the background pigmentation and redness.

Another reason for improving the current classification system is that coloring on the face and body may not match.

This LED device, manufactured by Palomar Medical Technologies Inc., is pending approval. The hope is that it will be released by summer's end, he said.

Photopneumatic laser therapy, another new device, manufactured by Aesthera Corp., has been cleared by the FDA for hair removal and skin rejuvenation. However, it is being used off label to treat acne and is in clinical trials for that indication.

The theory behind this device is very intriguing, in that is uses suction and lower wavelengths of light, explained Dr. Narurkar. "When we treat acne with lasers, we either try to destroy the Propionibacterium acnes bacteria with devices that are in the blue light wavelength, or we try to modify the sebaceous glands with devices that are in the red light wavelength," he said. A suction-based device can be brought closer to the skin and simultaneously is able to address both the P. acnes bacteria and the sebaceous glands. The photopneumatic laser uses a lower band of light, which allows for better absorption.

"In our clinical study, we saw an immediate improvement in the inflammatory component of acne, and then more of a delayed effect in the reduction of new acne lesions," Dr. Narurkar explained. "The device is in clinical trials right now."

Dr. Narurkar is a member of the medical advisory board of Aesthera, and he performs clinical studies for Palomar Medical Technologies.

BOCA RATON, FLA. — A new light-emitting diode device awaiting approval and an expected expanded indication for a laser are poised to expand the dermatologic device armamentarium, Dr. Vic Narurkar said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"One of the most exciting technologies to come out this year is a dermal spectrophotometer, because it will be a way of determining the skin's erythema and melanin content," said Dr. Narurkar, a dermatologist in private practice in San Francisco.

This advance is needed because the Fitzgerald skin type classification is outdated, he explained. "Darker skin often gets lumped into the Fitzpatrick IV, V, and VI, when there are many variations within all of those skin types," he said.

A far better method is to have some type of computer model determine the pigmentation and redness, as well as the background pigmentation and redness.

Another reason for improving the current classification system is that coloring on the face and body may not match.

This LED device, manufactured by Palomar Medical Technologies Inc., is pending approval. The hope is that it will be released by summer's end, he said.

Photopneumatic laser therapy, another new device, manufactured by Aesthera Corp., has been cleared by the FDA for hair removal and skin rejuvenation. However, it is being used off label to treat acne and is in clinical trials for that indication.

The theory behind this device is very intriguing, in that is uses suction and lower wavelengths of light, explained Dr. Narurkar. "When we treat acne with lasers, we either try to destroy the Propionibacterium acnes bacteria with devices that are in the blue light wavelength, or we try to modify the sebaceous glands with devices that are in the red light wavelength," he said. A suction-based device can be brought closer to the skin and simultaneously is able to address both the P. acnes bacteria and the sebaceous glands. The photopneumatic laser uses a lower band of light, which allows for better absorption.

"In our clinical study, we saw an immediate improvement in the inflammatory component of acne, and then more of a delayed effect in the reduction of new acne lesions," Dr. Narurkar explained. "The device is in clinical trials right now."

Dr. Narurkar is a member of the medical advisory board of Aesthera, and he performs clinical studies for Palomar Medical Technologies.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” Dr. Spitzer said. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., of Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient, and the risk of cancer is small. And our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” he said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” he said. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer said that while CIN 2 has premalignant potential, overtreatment with loop electrosurgical excision can also have consequences.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” Dr. Spitzer said. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., of Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient, and the risk of cancer is small. And our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” he said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” he said. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer said that while CIN 2 has premalignant potential, overtreatment with loop electrosurgical excision can also have consequences.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” Dr. Spitzer said. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., of Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient, and the risk of cancer is small. And our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” he said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” he said. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer said that while CIN 2 has premalignant potential, overtreatment with loop electrosurgical excision can also have consequences.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” said Dr. Spitzer. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., an associate professor of family medicine and obstetrics and gynecology at Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient and the risk of cancer is small, and our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” Dr. Mayeux said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” said Dr. Mayeaux. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice, and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer pointed out that while there is no doubt that CIN 2 has some premalignant potential, overtreatment with the loop electrosurgical excision procedure can also have consequences.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” said Dr. Spitzer. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., an associate professor of family medicine and obstetrics and gynecology at Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient and the risk of cancer is small, and our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” Dr. Mayeux said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” said Dr. Mayeaux. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice, and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer pointed out that while there is no doubt that CIN 2 has some premalignant potential, overtreatment with the loop electrosurgical excision procedure can also have consequences.

LAS VEGAS — Experts are divided on how aggressively cervical intraepithelial neoplasia grade 2 should be treated, and on whether observation is an acceptable option, especially in low-risk populations.

Cervical intraepithelial neoplasia (CIN) has been regarded as a preinvasive condition, with progressively higher grades being associated with an increasing risk of cancer. As most CIN 1 lesions regress without treatment, it has been suggested that CIN 2 may also have limited potential to progress to a more invasive disease.

“The goal of treatment for CIN is to prevent cancer by eliminating lesions with true malignant potential,” Dr. Mark Spitzer said at a meeting of the American Society for Colposcopy and Cervical Pathology. “And we also want to avoid unnecessary treatment of lesions with little or no premalignant potential.”

The data are mixed, said Dr. Spitzer of New York University, New York. Some studies show that CIN 2 is an intermediate entity that lies between CIN 1 and CIN 3 and has some premalignant potential although not as great as that of CIN 3. Other studies show that it is much closer to CIN 1 or benign disease, so it does not have real premalignant potential.

That raises the question, “Is the diagnosis of CIN 2 a reliable or reproducible diagnosis?” Dr. Spitzer said.

He pointed out that a few studies have assessed that question, and one concluded that interobserver variation is fair to good for the diagnosis of benign conditions, CIN 3, or invasive cancer, but poor for the diagnosis of CIN 1 or CIN 2. There is also poorer correlation between colposcopic and histologic diagnosis with CIN 2, compared with CIN 1 and CIN 3.

“The problem with CIN 2 is that we don't really know what it is,” Dr. Spitzer said. Any system of grading an intraepithelial lesion, in which there is a lesional continuum, is essentially artificial. A grading system that is based on light microscopy is subject to inter- and intraobserver variations in reporting, and treating all patients with CIN 2 will clearly result in the overtreatment of many of them.

There's also a question of age, when making the decision to treat cervical lesions. CIN 2 in adolescents is different than it is in adults, he explained. Some preliminary results showed that after 1 year, the behavior of CIN 2 in adolescents was the same as that of CIN 1.

“If you're under 20 the risk of invasive cancer is zero,” said Dr. Spitzer. “If you're in the cohort under age 25, it still is really very low. So not treating CIN 2 in younger patients really makes a lot of sense.”

However, Dr. Edward John Mayeaux Jr., an associate professor of family medicine and obstetrics and gynecology at Louisiana State University, Shreveport, disagreed with the assumption that CIN 2 isn't a real entity. “This has been debated before,” he said, “And the data do show that it is different in its progression and regression potential than CIN 1. It has a biological activity that is different from both CIN 1 and CIN 3.

“In adolescents it is often transient and the risk of cancer is small, and our guidelines already say that observation for 1 year is acceptable for adolescents with CIN 2,” Dr. Mayeux said.

Dr. Mayeaux also pointed out that in the United States, CIN 2 and 3 are managed in a similar fashion, primarily because the potential for progression is higher than that of CIN 1 and reliable histologic differentiation in CIN 2 and 3 is only moderate.

Overall, CIN 3 has about a 12% progression to cancer, but CIN 2 has about a 5% progression to cancer. These estimates do vary significantly, and at this time, most authors, guidelines, and professional organizations do recommend treatment for both CIN 2 and 3 lesions.

“We do need a better way to tell who is going to progress, and I agree with that,” said Dr. Mayeaux. “The difference in our point of view is that I don't think we're there yet. And until we get there, we don't know what those changes are going to mean for patient outcome. We still need to treat it until we reach that point.”

Given the current variations in equipment and practice, and the greater potential of CIN 2 to progress, compared with CIN 1, Dr. Mayeaux recommends no changes in current treatment protocols.

In rebuttal, Dr. Spitzer pointed out that while there is no doubt that CIN 2 has some premalignant potential, overtreatment with the loop electrosurgical excision procedure can also have consequences.

SEATTLE – Anxiety disorders are associated with a wide range of physical health problems, even after adjustment for other common mental disorders such as depression, Dr. Jitender Sareen said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. They used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was used to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, and social phobia.

The investigators looked at disability and functional impairment, and then controlled for factors such as depression, alcohol use, and pain. But even after they adjusted for common mood and substance abuse disorders, pain, and sociodemographics, anxiety disorders remained associated with a high level of disability and greater role impairment.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition. Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent. Other associated disorders included vascular conditions, respiratory illnesses, gastrointestinal disease, bone or joint disorders, and diseases like cancer and AIDS.

Subjects reporting a diagnosis of panic attacks and agoraphobia were also highly likely to have a comorbid medical condition, especially a vascular disease or a bone or joint disorder. Dr. Sareen and his colleagues found that generalized anxiety disorder and social or simple phobias were also associated with physical illnesses, but the prevalence was lower.

There is a strong and unique association between anxiety disorders and physical disorders, the researchers concluded, and the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” he said.

SEATTLE – Anxiety disorders are associated with a wide range of physical health problems, even after adjustment for other common mental disorders such as depression, Dr. Jitender Sareen said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. They used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was used to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, and social phobia.

The investigators looked at disability and functional impairment, and then controlled for factors such as depression, alcohol use, and pain. But even after they adjusted for common mood and substance abuse disorders, pain, and sociodemographics, anxiety disorders remained associated with a high level of disability and greater role impairment.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition. Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent. Other associated disorders included vascular conditions, respiratory illnesses, gastrointestinal disease, bone or joint disorders, and diseases like cancer and AIDS.

Subjects reporting a diagnosis of panic attacks and agoraphobia were also highly likely to have a comorbid medical condition, especially a vascular disease or a bone or joint disorder. Dr. Sareen and his colleagues found that generalized anxiety disorder and social or simple phobias were also associated with physical illnesses, but the prevalence was lower.

There is a strong and unique association between anxiety disorders and physical disorders, the researchers concluded, and the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” he said.

SEATTLE – Anxiety disorders are associated with a wide range of physical health problems, even after adjustment for other common mental disorders such as depression, Dr. Jitender Sareen said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. They used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was used to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, and social phobia.

The investigators looked at disability and functional impairment, and then controlled for factors such as depression, alcohol use, and pain. But even after they adjusted for common mood and substance abuse disorders, pain, and sociodemographics, anxiety disorders remained associated with a high level of disability and greater role impairment.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition. Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent. Other associated disorders included vascular conditions, respiratory illnesses, gastrointestinal disease, bone or joint disorders, and diseases like cancer and AIDS.

Subjects reporting a diagnosis of panic attacks and agoraphobia were also highly likely to have a comorbid medical condition, especially a vascular disease or a bone or joint disorder. Dr. Sareen and his colleagues found that generalized anxiety disorder and social or simple phobias were also associated with physical illnesses, but the prevalence was lower.

There is a strong and unique association between anxiety disorders and physical disorders, the researchers concluded, and the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” he said.

SEATTLE — The introduction of “MELD/PELD” 3 years ago was a start, but the liver allocation system is continually undergoing adjustments and refinements in an effort to improve outcomes, said Michael R. Lucey, M.D., at the annual meeting of the American Transplant Congress.

The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) are numeric scales that in 2002 replaced the former system used for liver allocation. Both scores are based on a patient's risk of dying while waiting for a liver transplant, and both use objective and verifiable medical data. The higher the MELD or PELD score, the greater the risk of dying from liver disease.

The MELD score uses a mathematical formula based on serum creatinine levels, bilirubin levels, and international normalized ratio. A patient's score can range from 6 to 40. In the event of a liver becoming available to two patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor. In the first year of utilizing MELD scores, the median score of patients who received livers was 18 to 20, with a few spikes to 24 and 27, said Dr. Lucey.

Before the implementation of the MELD/PELD system, there were large disparities in waiting times across geographic regions, as well as difficulties in prioritizing patients.

While the situation has improved, there are still regional variations, said Dr. Lucey, chief of gastroenterology and hepatology at the University of Wisconsin, Madison.

“We have 11 regions and there are regional variations in mean MELD scores, from a high point of 27 to low point of 20,” he said.

In some organ procurement organizations (OPOs), no patients with a MELD of less than 10 received a transplant. Yet in others, as many as 17 or 18 patients whose MELD score was below 10 received a liver transplant.

“So the MELD system demonstrates that not only are there regional variations, but variations between OPOs,” said Dr. Lucey at the meeting, which was cosponsored by the American Society of Transplantation and the American Society of Transplant Surgeons.

One analysis showed that the size of the OPO was associated with how the MELD score was implemented.

It found a significant disparity in MELD scores in liver transplant recipients in small versus large OPOs. Fewer transplant recipients in small OPOs had severe liver disease, as evidenced by MELD scores below 24, he said.

“The smaller OPOs tend to transplant patients who are less severely ill,” said Dr. Lucey.

“There are distinct practices across the country and between OPOs, [although] one of the priorities of MELD was to make geographic distinctions less important in organ allocation.”

This disparity, he added, does not reflect the stated goals of the current allocation policy, which is to distribute livers according to a patient's medical need, rather than to keep organs in the local procurement area.

Patients awaiting livers used to be ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. The status 1 category has remained in place as the highest priority for receiving an organ and is not affected by the MELD or PELD scores.

A high number of pediatric patients were being transplanted at stage 1 before PELD, with half of them at status 1 and 23% at status 1 by exception.

“But since PELD, there has been a minor reduction in the total number of status 1 transplants, but an increase in those getting status 1 transplants by exception,” said Dr. Lucey. “This calls for a review.”

Another issue is that more than half of the transplant candidates are listed with PELD scores of less than 10, and many such patients are being transplanted. It is important to find out what this means, he explained.

“Status 1 has been redefined for PELD, and we will have to see if stricter rules to define status 1 have had an impact—and an impact that we want,” he said.

MELD and PELD have made it easier to audit the practice of liver transplantation, Dr. Lucey concluded.

“They facilitate data-driven changes in policy and practice and, finally, allow for subsequent auditing after the changes are made, with continuing revisions as appear appropriate.”

SEATTLE — The introduction of “MELD/PELD” 3 years ago was a start, but the liver allocation system is continually undergoing adjustments and refinements in an effort to improve outcomes, said Michael R. Lucey, M.D., at the annual meeting of the American Transplant Congress.

The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) are numeric scales that in 2002 replaced the former system used for liver allocation. Both scores are based on a patient's risk of dying while waiting for a liver transplant, and both use objective and verifiable medical data. The higher the MELD or PELD score, the greater the risk of dying from liver disease.

The MELD score uses a mathematical formula based on serum creatinine levels, bilirubin levels, and international normalized ratio. A patient's score can range from 6 to 40. In the event of a liver becoming available to two patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor. In the first year of utilizing MELD scores, the median score of patients who received livers was 18 to 20, with a few spikes to 24 and 27, said Dr. Lucey.

Before the implementation of the MELD/PELD system, there were large disparities in waiting times across geographic regions, as well as difficulties in prioritizing patients.

While the situation has improved, there are still regional variations, said Dr. Lucey, chief of gastroenterology and hepatology at the University of Wisconsin, Madison.

“We have 11 regions and there are regional variations in mean MELD scores, from a high point of 27 to low point of 20,” he said.

In some organ procurement organizations (OPOs), no patients with a MELD of less than 10 received a transplant. Yet in others, as many as 17 or 18 patients whose MELD score was below 10 received a liver transplant.

“So the MELD system demonstrates that not only are there regional variations, but variations between OPOs,” said Dr. Lucey at the meeting, which was cosponsored by the American Society of Transplantation and the American Society of Transplant Surgeons.

One analysis showed that the size of the OPO was associated with how the MELD score was implemented.

It found a significant disparity in MELD scores in liver transplant recipients in small versus large OPOs. Fewer transplant recipients in small OPOs had severe liver disease, as evidenced by MELD scores below 24, he said.

“The smaller OPOs tend to transplant patients who are less severely ill,” said Dr. Lucey.

“There are distinct practices across the country and between OPOs, [although] one of the priorities of MELD was to make geographic distinctions less important in organ allocation.”

This disparity, he added, does not reflect the stated goals of the current allocation policy, which is to distribute livers according to a patient's medical need, rather than to keep organs in the local procurement area.

Patients awaiting livers used to be ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. The status 1 category has remained in place as the highest priority for receiving an organ and is not affected by the MELD or PELD scores.

A high number of pediatric patients were being transplanted at stage 1 before PELD, with half of them at status 1 and 23% at status 1 by exception.

“But since PELD, there has been a minor reduction in the total number of status 1 transplants, but an increase in those getting status 1 transplants by exception,” said Dr. Lucey. “This calls for a review.”

Another issue is that more than half of the transplant candidates are listed with PELD scores of less than 10, and many such patients are being transplanted. It is important to find out what this means, he explained.

“Status 1 has been redefined for PELD, and we will have to see if stricter rules to define status 1 have had an impact—and an impact that we want,” he said.

MELD and PELD have made it easier to audit the practice of liver transplantation, Dr. Lucey concluded.

“They facilitate data-driven changes in policy and practice and, finally, allow for subsequent auditing after the changes are made, with continuing revisions as appear appropriate.”

SEATTLE — The introduction of “MELD/PELD” 3 years ago was a start, but the liver allocation system is continually undergoing adjustments and refinements in an effort to improve outcomes, said Michael R. Lucey, M.D., at the annual meeting of the American Transplant Congress.

The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) are numeric scales that in 2002 replaced the former system used for liver allocation. Both scores are based on a patient's risk of dying while waiting for a liver transplant, and both use objective and verifiable medical data. The higher the MELD or PELD score, the greater the risk of dying from liver disease.

The MELD score uses a mathematical formula based on serum creatinine levels, bilirubin levels, and international normalized ratio. A patient's score can range from 6 to 40. In the event of a liver becoming available to two patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor. In the first year of utilizing MELD scores, the median score of patients who received livers was 18 to 20, with a few spikes to 24 and 27, said Dr. Lucey.

Before the implementation of the MELD/PELD system, there were large disparities in waiting times across geographic regions, as well as difficulties in prioritizing patients.

While the situation has improved, there are still regional variations, said Dr. Lucey, chief of gastroenterology and hepatology at the University of Wisconsin, Madison.

“We have 11 regions and there are regional variations in mean MELD scores, from a high point of 27 to low point of 20,” he said.

In some organ procurement organizations (OPOs), no patients with a MELD of less than 10 received a transplant. Yet in others, as many as 17 or 18 patients whose MELD score was below 10 received a liver transplant.

“So the MELD system demonstrates that not only are there regional variations, but variations between OPOs,” said Dr. Lucey at the meeting, which was cosponsored by the American Society of Transplantation and the American Society of Transplant Surgeons.

One analysis showed that the size of the OPO was associated with how the MELD score was implemented.

It found a significant disparity in MELD scores in liver transplant recipients in small versus large OPOs. Fewer transplant recipients in small OPOs had severe liver disease, as evidenced by MELD scores below 24, he said.

“The smaller OPOs tend to transplant patients who are less severely ill,” said Dr. Lucey.

“There are distinct practices across the country and between OPOs, [although] one of the priorities of MELD was to make geographic distinctions less important in organ allocation.”

This disparity, he added, does not reflect the stated goals of the current allocation policy, which is to distribute livers according to a patient's medical need, rather than to keep organs in the local procurement area.

Patients awaiting livers used to be ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. The status 1 category has remained in place as the highest priority for receiving an organ and is not affected by the MELD or PELD scores.

A high number of pediatric patients were being transplanted at stage 1 before PELD, with half of them at status 1 and 23% at status 1 by exception.

“But since PELD, there has been a minor reduction in the total number of status 1 transplants, but an increase in those getting status 1 transplants by exception,” said Dr. Lucey. “This calls for a review.”

Another issue is that more than half of the transplant candidates are listed with PELD scores of less than 10, and many such patients are being transplanted. It is important to find out what this means, he explained.

“Status 1 has been redefined for PELD, and we will have to see if stricter rules to define status 1 have had an impact—and an impact that we want,” he said.

MELD and PELD have made it easier to audit the practice of liver transplantation, Dr. Lucey concluded.

“They facilitate data-driven changes in policy and practice and, finally, allow for subsequent auditing after the changes are made, with continuing revisions as appear appropriate.”

SEATTLE — Anxiety disorders are associated with a wide range of physical health problems, even after adjusting for other common mental disorders such as depression, Jitender Sareen, M.D., said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen, of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. The researchers used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was employed to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, social phobia, and simple phobia.

Dr. Sareen and his associates looked at disability and functional impairment, and controlled for factors such as depression, alcohol use, and pain. Even after adjusting for common mood and substance abuse disorders, pain, and sociodemographics, they found that anxiety disorders were associated with a high level of disability.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition (adjusted odds ratio 3.26). Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent (adjusted odds ratio 2.84).

The presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” Dr. Sareen said. “And what we are showing is that not only are they related, but they raise disability in the community.”

SEATTLE — Anxiety disorders are associated with a wide range of physical health problems, even after adjusting for other common mental disorders such as depression, Jitender Sareen, M.D., said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen, of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. The researchers used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was employed to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, social phobia, and simple phobia.

Dr. Sareen and his associates looked at disability and functional impairment, and controlled for factors such as depression, alcohol use, and pain. Even after adjusting for common mood and substance abuse disorders, pain, and sociodemographics, they found that anxiety disorders were associated with a high level of disability.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition (adjusted odds ratio 3.26). Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent (adjusted odds ratio 2.84).

The presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” Dr. Sareen said. “And what we are showing is that not only are they related, but they raise disability in the community.”

SEATTLE — Anxiety disorders are associated with a wide range of physical health problems, even after adjusting for other common mental disorders such as depression, Jitender Sareen, M.D., said in a poster presentation at the annual conference of the Anxiety Disorders Association of America.

“There has long been an interest in understanding how depression affects physical health,” said Dr. Sareen, of the department of psychiatry at the University of Manitoba, Winnipeg. “However, there have only been a few studies which have examined the relationship between anxiety disorders and medical conditions.”

The researchers used data derived from the U.S. National Comorbidity Survey, a national representative sample of 5,877 individuals aged 15–54 years, to examine the relationship between anxiety disorders and a wide range of medical conditions. The researchers used the Composite International Diagnostic Interview to make DSM-III-R mental disorder diagnoses, and assessed participants' general physical conditions on the basis of self-report. Multiple logistic regression was employed to analyze the relationship between a past-year anxiety disorder diagnosis and past-year chronic physical illness.

Anxiety disorders diagnosed among the survey participants during the previous year included posttraumatic stress disorder, panic attacks, agoraphobia, generalized anxiety disorder, social phobia, and simple phobia.

Dr. Sareen and his associates looked at disability and functional impairment, and controlled for factors such as depression, alcohol use, and pain. Even after adjusting for common mood and substance abuse disorders, pain, and sociodemographics, they found that anxiety disorders were associated with a high level of disability.

Among the anxiety disorders, posttraumatic stress disorder was linked to the widest range of physical conditions, with the most prevalent being any type of metabolic or autoimmune condition (adjusted odds ratio 3.26). Neurologic conditions, including epilepsy, multiple sclerosis, and stroke, were also highly prevalent (adjusted odds ratio 2.84).

The presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

“We have found that anxiety disorders are related to physical health, much in the same way that depression is,” Dr. Sareen said. “And what we are showing is that not only are they related, but they raise disability in the community.”

SEATTLE — The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral therapy.

The children who responded to cognitive-behavioral therapy (CBT) were also able to reduce the symptoms of their comorbid disorders, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg.

In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder.

The primary diagnosis was the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P).

The intensive CBT for specific phobias called “One Session Treatment,” included the techniques of in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring in a single session.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

The study is ongoing, Dr. Ollendick said, but the numbers so far are robust.

SEATTLE — The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral therapy.

The children who responded to cognitive-behavioral therapy (CBT) were also able to reduce the symptoms of their comorbid disorders, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg.

In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder.

The primary diagnosis was the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P).

The intensive CBT for specific phobias called “One Session Treatment,” included the techniques of in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring in a single session.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

The study is ongoing, Dr. Ollendick said, but the numbers so far are robust.

SEATTLE — The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral therapy.

The children who responded to cognitive-behavioral therapy (CBT) were also able to reduce the symptoms of their comorbid disorders, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg.

In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder.

The primary diagnosis was the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule, Child and Parent versions (ADIS-C/P).

The intensive CBT for specific phobias called “One Session Treatment,” included the techniques of in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring in a single session.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

The study is ongoing, Dr. Ollendick said, but the numbers so far are robust.

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.

SEATTLE — Liver transplant candidates, along with members of their households, should receive all recommended vaccines well before transplantation.

It is important that transplant candidates are vaccinated early in the course of their disease because the response to many vaccines is decreased when the patient is in organ failure, said Hugo Vargas, M.D., at the American Transplant Congress.

“We really need to target patients before they are put on the waiting list for a transplant,” explained Dr. Vargas of the division of transplantation medicine at the Mayo Clinic, Scottsdale, Ariz. “We need to target cirrhotic patients and prevent the development of hepatitis and pneumonia.”

Ideally, vaccination status should be reviewed during the patient's first clinic visit, and a vaccine strategy should be developed at that time.

It is especially important that live vaccines, such as varicella, be administered before transplantation is performed as they cannot be given afterward, said Dr. Vargas.

“You want to know the patient's history, what they are at risk for, and then check their vaccination status,” he explained. “It is important to find out who lives in the household. Are there children? Have they been immunized? Are there any live vaccines needed for the patient or the household?”

Two of the most important vaccines for a liver transplant candidate are hepatitis A (HAV) and hepatitis B (HBV). There is strong evidence that HAV can worsen outcomes in this population, and morbidity can be as much as 50 times higher with HAV and HBV coinfection.

Some data suggest that mortality for patients infected with acute HAV is 23% higher than for those without hepatitis, and HAV can sometimes cause fulminant liver disease.

Immunization against HBV is also important. However, the response rate to the vaccine is low when chronic liver disease is present.

“My recommendation is to identify if your patients are infected, and if they are seronegative, you should schedule a vaccine,” Dr. Vargas said, “because once the patient has been transplanted, the response is very poor.”

Patients with cirrhosis are at increased risk for pneumonia, and the Centers for Disease Control and Prevention recommends that this population be vaccinated for pneumonia. Adult patients should be given the pneumococcal polysaccharide 23-valent vaccine, which offers protection against Streptococcus pneumoniae, the most common cause of adult community-acquired and nursing home-acquired pneumonia. The vaccine needs to be repeated after 5 years if the patient is younger than 65.

Certain individuals, such as those in the military, travelers to high-risk areas, and college freshmen living on campus are also candidates for the meningococcal vaccine, which protects against meningitis caused by Neisseria meningitidis.

Dr. Vargas also pointed out the importance of getting vaccinated annually for influenza A, with the injectable formulation; patients with cirrhosis, however, will need two injections to achieve an 80% response.

“Overall, the strategy needs to consider the vaccination status not only of the patient, but of the family and health care workers as well,” he said.

SEATTLE – The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral treatment.

The children who responded to cognitive-behavioral treatment (CBT) were also able to reduce the symptoms of their comorbid disorder, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg. In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder, Dr. Ollendick reported.

The primary diagnosis was determined as the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule for Children and Parent (ADIS-C/P).

Treatment was an intensive CBT for specific phobias called “One Session Treatment,” which was implemented in a single session and involved several CBT techniques, including in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring.

Another therapy, known as Educational Supportive Treatment (EST), served as a control and did not provide exposure to fear-producing stimuli or modeling of contact with the phobic object.

The study is still in progress, Dr. Ollendick said, but based on the data found so far, the numbers are robust.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

Response rates to EST were much lower, compared with intensive CBT. But no significant difference was found between subjects with and without a comorbid condition.

Another finding was that treating for a specific phobia also had an impact on the comorbid disorder. Before receiving therapy, 77% of the children had at least one additional diagnosis, but at posttreatment, that percentage had declined to 48.6%.

“It is very important to know that treatment can work with children who are more complex, and we found that it worked very well,” Dr. Ollendick said.

SEATTLE – The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral treatment.

The children who responded to cognitive-behavioral treatment (CBT) were also able to reduce the symptoms of their comorbid disorder, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg. In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder, Dr. Ollendick reported.

The primary diagnosis was determined as the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule for Children and Parent (ADIS-C/P).

Treatment was an intensive CBT for specific phobias called “One Session Treatment,” which was implemented in a single session and involved several CBT techniques, including in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring.

Another therapy, known as Educational Supportive Treatment (EST), served as a control and did not provide exposure to fear-producing stimuli or modeling of contact with the phobic object.

The study is still in progress, Dr. Ollendick said, but based on the data found so far, the numbers are robust.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

Response rates to EST were much lower, compared with intensive CBT. But no significant difference was found between subjects with and without a comorbid condition.

Another finding was that treating for a specific phobia also had an impact on the comorbid disorder. Before receiving therapy, 77% of the children had at least one additional diagnosis, but at posttreatment, that percentage had declined to 48.6%.

“It is very important to know that treatment can work with children who are more complex, and we found that it worked very well,” Dr. Ollendick said.

SEATTLE – The presence of a comorbid anxiety disorder in children with phobias does not interfere with the child's ability to respond to cognitive-behavioral treatment.

The children who responded to cognitive-behavioral treatment (CBT) were also able to reduce the symptoms of their comorbid disorder, according to data presented by Thomas H. Ollendick, Ph.D., at the annual meeting of the Anxiety Disorders Association of America.

“The presence of a comorbid anxiety disorder made no difference and did not interfere with the ability to treat,” reported Dr. Ollendick, in a poster presentation. “There was no difference as to the type of comorbidity, although we did exclude comorbid disorders such as autism and schizophrenia, which generally cause more severe impairment.”

The rates of comorbidity in children with anxiety are significant. But the impact of comorbidity on treatment efficacy is relatively unknown, and this area has not been well studied, said Dr. Ollendick, professor of psychology and director of the Child Study Center at Virginia Polytechnic Institute and State University in Blacksburg. In fact, no studies have been undertaken looking at the influence of specific treatments on nontargeted comorbid conditions.

The investigators evaluated treatment efficacy in 105 children aged 7–16 years, who met the DSM-IV criteria for a specific phobia based on a pretreatment structured interview.

Within the group, 22.8% had a specific phobia (SP) only, 42.8% had an SP as their primary diagnosis and another untreated SP as a secondary diagnosis, 29.5% had a generalized anxiety disorder as a secondary diagnosis, 17.1% were diagnosed with comorbid separation anxiety disorder, 17.1% had comorbid social anxiety disorder, and 12.4% had comorbid attention-deficit hyperactivity disorder, Dr. Ollendick reported.

The primary diagnosis was determined as the one causing the greatest interference and distress for the child, based on the Anxiety Disorders Interview Schedule for Children and Parent (ADIS-C/P).

Treatment was an intensive CBT for specific phobias called “One Session Treatment,” which was implemented in a single session and involved several CBT techniques, including in vivo exposure, participant modeling, social reinforcement, and cognitive restructuring.

Another therapy, known as Educational Supportive Treatment (EST), served as a control and did not provide exposure to fear-producing stimuli or modeling of contact with the phobic object.

The study is still in progress, Dr. Ollendick said, but based on the data found so far, the numbers are robust.

Children with a specific phobia had a 62.5% response rate to CBT, compared with 53.8% of those with an accompanying comorbid anxiety disorder.

Response rates to EST were much lower, compared with intensive CBT. But no significant difference was found between subjects with and without a comorbid condition.

Another finding was that treating for a specific phobia also had an impact on the comorbid disorder. Before receiving therapy, 77% of the children had at least one additional diagnosis, but at posttreatment, that percentage had declined to 48.6%.

“It is very important to know that treatment can work with children who are more complex, and we found that it worked very well,” Dr. Ollendick said.