Sharon Worcester

BAL HARBOUR, FLA. — Infections are a major cause of emergencies in pediatric dermatology, Howard Pride, M.D., said at the annual Masters of Pediatrics Conference sponsored by the University of Miami.

Though rare, such conditions must be kept in mind to ensure prompt diagnosis and appropriate treatment. Staphylococcal scalded skin syndrome, for example, is often thought to be a nondeadly disease, but it is associated with a mortality of up to 7%, particularly in the very young and should be identified early, said Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa.

The disease presents with a scarlet fever-like rash, usually beginning around the lips and nose and then becoming more generalized with flexural accentuation in the groin area; it may involve superficial bullae that rapidly denude and leave large areas of raw, red, moist skin that appears scalded. It typically occurs in children younger than 5 years.

Onset is abrupt and includes irritability, malaise, fever, and extreme pain. In fact, pain is often the dominant symptom, Dr. Pride noted.

Staphylococcus aureus is the associated pathogen, but exfoliative toxins A and B, either of which is released at the infection site and spreads hematogenously, are the cause of the lesions. Therefore, cultures of the blisters are not useful.

The diagnosis is typically made clinically; there is little in the way of diagnostic testing for scalded skin syndrome. Biopsies or cultures of the eyes, nose, or pharynx can be performed, but Dr. Pride said he biopsies only on rare occasions.

For the most part, diagnosis is based on clinical intuition. However, for a rapid diagnosis and to differentiate this from toxic epidermal necrolysis, a snap frozen section can be performed.

Care for staphylococcal scalded skin syndrome is mostly supportive; skin care includes application of emollients, such as a petrolatum ointment. Mupirocin is not necessary since staphylococcus is not the direct cause of the skin lesions.

Strict attention to fluids and electrolytes is important, as is maintenance of body temperature. Antibiotic treatment against staphylococcus is useful, but a few articles have shown that some cases in adults have been associated with methicillin-resistant Staphylococcus aureus, so keep this in mind when considering antibiotic coverage, Dr. Pride advised.

“But the best thing we can do for these patients is control pain, because they are absolutely miserable,” he said.

Other pediatric emergencies that Dr. Pride discussed include:

▸ Ecthyma gangrenosum. Lesions associated with this condition, which almost always occurs in the setting of immunocompromise, have a central hemorrhage with a purplish halo. They may have a punched-out ulcer appearance with a necrotic base and black eschar. They commonly occur in patients undergoing chemotherapy, and Pseudomonas aeruginosa is usually the culprit, Dr. Pride said. But other organisms, such as herpes simplex, S. aureus, and species of Klebsiella, Neisseria, and Candida may be involved.

“But when you think about empirical coverage [P. aeruginosa] is the organism you really want to be covering,” he said.

The diagnosis is usually made clinically, and supportive measures along with a broad-spectrum antibiotic should be initiated to ensure coverage while awaiting culture or biopsy results. Aspiration or drainage of lesions should be performed as necessary.

▸ Meningococcemia. This is a scary and sometimes rapidly progressing disease that also requires quick action. Presentation includes high fever, headache, nausea, diarrhea, and a petechial rash of the skin and mucous membranes. The fulminant form presents with massive skin and mucosal hemorrhage, shock, and rapid death. Peripheral gangrene can occur.

Rapid antigen tests exist, but specificity is not very high, so the diagnosis should be made clinically, and treatment should be initiated quickly in an intensive care unit. Penicillin remains the treatment of choice for this condition, and supportive care and skin care with mupirocin are useful. Prophylaxis of patient contacts is imperative, he said.

▸ Rocky mountain spotted fever. The peak incidence of this often tick-borne illness, which generally occurs in the southeastern and south central United States in early summer, is in children 5–9 years old. They present with sudden severe headache, malaise, myalgia, arthralgia, anorexia, photophobia, chills, and fever. Hypotension also can occur.

A rash, which progresses centrally and mostly affects the extremities, occurs on the fourth day of illness in about 90% of patients. Early in the course of illness, the rash appears with small discrete red blanching macules, which later become papules with a dark hue. The extremities have a nonpitted edematous characteristic, and in young children the rash may occur periorbitally.

About 80% of patients report a recent tick bite.

Like the other pediatric emergencies Dr. Pride discussed, this diagnosis is made clinically; good diagnostic tests are lacking.

Early treatment is important, because mortality ranges from 20% to 80% in untreated cases and is about 4% among treated cases.

Tetracyclines are the treatment of choice, with doxycycline preferred in patients younger than 8 years. Chloramphenicol is another treatment option.

Supportive care—often with intravenous hydration, supplemental oxygen and red blood cells—also is of benefit, he said.

Abrupt and extreme pain marks the onset of scalded skin syndrome. Staphylococcus often is the pathogen.

Chemotherapy increases vulnerability to ecthyma gangrenosum. Pseudomonas aeruginosa may cause it.

Meningococcemia is marked by rapid onset and petechial rash of skin and mucous membranes. Photos courtesy Dr. Howard Pride

BAL HARBOUR, FLA. — Infections are a major cause of emergencies in pediatric dermatology, Howard Pride, M.D., said at the annual Masters of Pediatrics Conference sponsored by the University of Miami.

Though rare, such conditions must be kept in mind to ensure prompt diagnosis and appropriate treatment. Staphylococcal scalded skin syndrome, for example, is often thought to be a nondeadly disease, but it is associated with a mortality of up to 7%, particularly in the very young and should be identified early, said Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa.

The disease presents with a scarlet fever-like rash, usually beginning around the lips and nose and then becoming more generalized with flexural accentuation in the groin area; it may involve superficial bullae that rapidly denude and leave large areas of raw, red, moist skin that appears scalded. It typically occurs in children younger than 5 years.

Onset is abrupt and includes irritability, malaise, fever, and extreme pain. In fact, pain is often the dominant symptom, Dr. Pride noted.

Staphylococcus aureus is the associated pathogen, but exfoliative toxins A and B, either of which is released at the infection site and spreads hematogenously, are the cause of the lesions. Therefore, cultures of the blisters are not useful.

The diagnosis is typically made clinically; there is little in the way of diagnostic testing for scalded skin syndrome. Biopsies or cultures of the eyes, nose, or pharynx can be performed, but Dr. Pride said he biopsies only on rare occasions.

For the most part, diagnosis is based on clinical intuition. However, for a rapid diagnosis and to differentiate this from toxic epidermal necrolysis, a snap frozen section can be performed.

Care for staphylococcal scalded skin syndrome is mostly supportive; skin care includes application of emollients, such as a petrolatum ointment. Mupirocin is not necessary since staphylococcus is not the direct cause of the skin lesions.

Strict attention to fluids and electrolytes is important, as is maintenance of body temperature. Antibiotic treatment against staphylococcus is useful, but a few articles have shown that some cases in adults have been associated with methicillin-resistant Staphylococcus aureus, so keep this in mind when considering antibiotic coverage, Dr. Pride advised.

“But the best thing we can do for these patients is control pain, because they are absolutely miserable,” he said.

Other pediatric emergencies that Dr. Pride discussed include:

▸ Ecthyma gangrenosum. Lesions associated with this condition, which almost always occurs in the setting of immunocompromise, have a central hemorrhage with a purplish halo. They may have a punched-out ulcer appearance with a necrotic base and black eschar. They commonly occur in patients undergoing chemotherapy, and Pseudomonas aeruginosa is usually the culprit, Dr. Pride said. But other organisms, such as herpes simplex, S. aureus, and species of Klebsiella, Neisseria, and Candida may be involved.

“But when you think about empirical coverage [P. aeruginosa] is the organism you really want to be covering,” he said.

The diagnosis is usually made clinically, and supportive measures along with a broad-spectrum antibiotic should be initiated to ensure coverage while awaiting culture or biopsy results. Aspiration or drainage of lesions should be performed as necessary.

▸ Meningococcemia. This is a scary and sometimes rapidly progressing disease that also requires quick action. Presentation includes high fever, headache, nausea, diarrhea, and a petechial rash of the skin and mucous membranes. The fulminant form presents with massive skin and mucosal hemorrhage, shock, and rapid death. Peripheral gangrene can occur.

Rapid antigen tests exist, but specificity is not very high, so the diagnosis should be made clinically, and treatment should be initiated quickly in an intensive care unit. Penicillin remains the treatment of choice for this condition, and supportive care and skin care with mupirocin are useful. Prophylaxis of patient contacts is imperative, he said.

▸ Rocky mountain spotted fever. The peak incidence of this often tick-borne illness, which generally occurs in the southeastern and south central United States in early summer, is in children 5–9 years old. They present with sudden severe headache, malaise, myalgia, arthralgia, anorexia, photophobia, chills, and fever. Hypotension also can occur.

A rash, which progresses centrally and mostly affects the extremities, occurs on the fourth day of illness in about 90% of patients. Early in the course of illness, the rash appears with small discrete red blanching macules, which later become papules with a dark hue. The extremities have a nonpitted edematous characteristic, and in young children the rash may occur periorbitally.

About 80% of patients report a recent tick bite.

Like the other pediatric emergencies Dr. Pride discussed, this diagnosis is made clinically; good diagnostic tests are lacking.

Early treatment is important, because mortality ranges from 20% to 80% in untreated cases and is about 4% among treated cases.

Tetracyclines are the treatment of choice, with doxycycline preferred in patients younger than 8 years. Chloramphenicol is another treatment option.

Supportive care—often with intravenous hydration, supplemental oxygen and red blood cells—also is of benefit, he said.

Abrupt and extreme pain marks the onset of scalded skin syndrome. Staphylococcus often is the pathogen.

Chemotherapy increases vulnerability to ecthyma gangrenosum. Pseudomonas aeruginosa may cause it.

Meningococcemia is marked by rapid onset and petechial rash of skin and mucous membranes. Photos courtesy Dr. Howard Pride

BAL HARBOUR, FLA. — Infections are a major cause of emergencies in pediatric dermatology, Howard Pride, M.D., said at the annual Masters of Pediatrics Conference sponsored by the University of Miami.

Though rare, such conditions must be kept in mind to ensure prompt diagnosis and appropriate treatment. Staphylococcal scalded skin syndrome, for example, is often thought to be a nondeadly disease, but it is associated with a mortality of up to 7%, particularly in the very young and should be identified early, said Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa.

The disease presents with a scarlet fever-like rash, usually beginning around the lips and nose and then becoming more generalized with flexural accentuation in the groin area; it may involve superficial bullae that rapidly denude and leave large areas of raw, red, moist skin that appears scalded. It typically occurs in children younger than 5 years.

Onset is abrupt and includes irritability, malaise, fever, and extreme pain. In fact, pain is often the dominant symptom, Dr. Pride noted.

Staphylococcus aureus is the associated pathogen, but exfoliative toxins A and B, either of which is released at the infection site and spreads hematogenously, are the cause of the lesions. Therefore, cultures of the blisters are not useful.

The diagnosis is typically made clinically; there is little in the way of diagnostic testing for scalded skin syndrome. Biopsies or cultures of the eyes, nose, or pharynx can be performed, but Dr. Pride said he biopsies only on rare occasions.

For the most part, diagnosis is based on clinical intuition. However, for a rapid diagnosis and to differentiate this from toxic epidermal necrolysis, a snap frozen section can be performed.

Care for staphylococcal scalded skin syndrome is mostly supportive; skin care includes application of emollients, such as a petrolatum ointment. Mupirocin is not necessary since staphylococcus is not the direct cause of the skin lesions.

Strict attention to fluids and electrolytes is important, as is maintenance of body temperature. Antibiotic treatment against staphylococcus is useful, but a few articles have shown that some cases in adults have been associated with methicillin-resistant Staphylococcus aureus, so keep this in mind when considering antibiotic coverage, Dr. Pride advised.

“But the best thing we can do for these patients is control pain, because they are absolutely miserable,” he said.

Other pediatric emergencies that Dr. Pride discussed include:

▸ Ecthyma gangrenosum. Lesions associated with this condition, which almost always occurs in the setting of immunocompromise, have a central hemorrhage with a purplish halo. They may have a punched-out ulcer appearance with a necrotic base and black eschar. They commonly occur in patients undergoing chemotherapy, and Pseudomonas aeruginosa is usually the culprit, Dr. Pride said. But other organisms, such as herpes simplex, S. aureus, and species of Klebsiella, Neisseria, and Candida may be involved.

“But when you think about empirical coverage [P. aeruginosa] is the organism you really want to be covering,” he said.

The diagnosis is usually made clinically, and supportive measures along with a broad-spectrum antibiotic should be initiated to ensure coverage while awaiting culture or biopsy results. Aspiration or drainage of lesions should be performed as necessary.

▸ Meningococcemia. This is a scary and sometimes rapidly progressing disease that also requires quick action. Presentation includes high fever, headache, nausea, diarrhea, and a petechial rash of the skin and mucous membranes. The fulminant form presents with massive skin and mucosal hemorrhage, shock, and rapid death. Peripheral gangrene can occur.

Rapid antigen tests exist, but specificity is not very high, so the diagnosis should be made clinically, and treatment should be initiated quickly in an intensive care unit. Penicillin remains the treatment of choice for this condition, and supportive care and skin care with mupirocin are useful. Prophylaxis of patient contacts is imperative, he said.

▸ Rocky mountain spotted fever. The peak incidence of this often tick-borne illness, which generally occurs in the southeastern and south central United States in early summer, is in children 5–9 years old. They present with sudden severe headache, malaise, myalgia, arthralgia, anorexia, photophobia, chills, and fever. Hypotension also can occur.

A rash, which progresses centrally and mostly affects the extremities, occurs on the fourth day of illness in about 90% of patients. Early in the course of illness, the rash appears with small discrete red blanching macules, which later become papules with a dark hue. The extremities have a nonpitted edematous characteristic, and in young children the rash may occur periorbitally.

About 80% of patients report a recent tick bite.

Like the other pediatric emergencies Dr. Pride discussed, this diagnosis is made clinically; good diagnostic tests are lacking.

Early treatment is important, because mortality ranges from 20% to 80% in untreated cases and is about 4% among treated cases.

Tetracyclines are the treatment of choice, with doxycycline preferred in patients younger than 8 years. Chloramphenicol is another treatment option.

Supportive care—often with intravenous hydration, supplemental oxygen and red blood cells—also is of benefit, he said.

Abrupt and extreme pain marks the onset of scalded skin syndrome. Staphylococcus often is the pathogen.

Chemotherapy increases vulnerability to ecthyma gangrenosum. Pseudomonas aeruginosa may cause it.

Meningococcemia is marked by rapid onset and petechial rash of skin and mucous membranes. Photos courtesy Dr. Howard Pride

ORLANDO, FLA.—Intrastricture steroid injections should be used routinely as part of the treatment for complex esophageal strictures caused by acid-peptic disease that are smaller than 13 mm, Tarun Mullick, M.D., said at the annual meeting of the American College of Gastroenterology.

In a randomized, placebo-controlled study of 120 patients, intrastricture Kenalog injections significantly reduced the number of dilations needed to achieve a successful outcome by an average of about three, when compared with sham injections (4 vs. 7 dilations). This reduced the number of days lost from work by patients in the steroid group, and also improved quality of life as measured in terms of dysphagia, the ability to take pills, and effects on diet, said Dr. Mullick of Delnor-Community Hospital, Geneva, Ill.

The findings represent a major advancement in the treatment of complex esophageal strictures caused by acid-peptic disease, but steroid injections should be reserved only for those strictures smaller than 13 mm in size, he said.

In this study, 40 of 60 patients in the steroid group and 45 of 60 in the sham injection group had strictures smaller than 13 mm, and the therapeutic benefit of the steroid injections was entirely limited to these strictures.

Significantly fewer patients in the steroid group than in the sham injection group failed to achieve a successful outcome (0/60 vs. 9/60), which was defined as dilation of at least 18 mm. Failure to progress to the next size dilator occurred 2 times in the steroid group, compared with 132 times in the sham injection group; this difference was also statistically significant.

The steroid and sham injection groups were similar in terms of demographics, and all patients in both groups were treated with a proton pump inhibitor and underwent gradual dilation of the stricture using fluoroscopically-assisted balloon dilation over a guidewire every 4-6 weeks.

ORLANDO, FLA.—Intrastricture steroid injections should be used routinely as part of the treatment for complex esophageal strictures caused by acid-peptic disease that are smaller than 13 mm, Tarun Mullick, M.D., said at the annual meeting of the American College of Gastroenterology.

In a randomized, placebo-controlled study of 120 patients, intrastricture Kenalog injections significantly reduced the number of dilations needed to achieve a successful outcome by an average of about three, when compared with sham injections (4 vs. 7 dilations). This reduced the number of days lost from work by patients in the steroid group, and also improved quality of life as measured in terms of dysphagia, the ability to take pills, and effects on diet, said Dr. Mullick of Delnor-Community Hospital, Geneva, Ill.

The findings represent a major advancement in the treatment of complex esophageal strictures caused by acid-peptic disease, but steroid injections should be reserved only for those strictures smaller than 13 mm in size, he said.

In this study, 40 of 60 patients in the steroid group and 45 of 60 in the sham injection group had strictures smaller than 13 mm, and the therapeutic benefit of the steroid injections was entirely limited to these strictures.

Significantly fewer patients in the steroid group than in the sham injection group failed to achieve a successful outcome (0/60 vs. 9/60), which was defined as dilation of at least 18 mm. Failure to progress to the next size dilator occurred 2 times in the steroid group, compared with 132 times in the sham injection group; this difference was also statistically significant.

The steroid and sham injection groups were similar in terms of demographics, and all patients in both groups were treated with a proton pump inhibitor and underwent gradual dilation of the stricture using fluoroscopically-assisted balloon dilation over a guidewire every 4-6 weeks.

ORLANDO, FLA.—Intrastricture steroid injections should be used routinely as part of the treatment for complex esophageal strictures caused by acid-peptic disease that are smaller than 13 mm, Tarun Mullick, M.D., said at the annual meeting of the American College of Gastroenterology.

In a randomized, placebo-controlled study of 120 patients, intrastricture Kenalog injections significantly reduced the number of dilations needed to achieve a successful outcome by an average of about three, when compared with sham injections (4 vs. 7 dilations). This reduced the number of days lost from work by patients in the steroid group, and also improved quality of life as measured in terms of dysphagia, the ability to take pills, and effects on diet, said Dr. Mullick of Delnor-Community Hospital, Geneva, Ill.

The findings represent a major advancement in the treatment of complex esophageal strictures caused by acid-peptic disease, but steroid injections should be reserved only for those strictures smaller than 13 mm in size, he said.

In this study, 40 of 60 patients in the steroid group and 45 of 60 in the sham injection group had strictures smaller than 13 mm, and the therapeutic benefit of the steroid injections was entirely limited to these strictures.

Significantly fewer patients in the steroid group than in the sham injection group failed to achieve a successful outcome (0/60 vs. 9/60), which was defined as dilation of at least 18 mm. Failure to progress to the next size dilator occurred 2 times in the steroid group, compared with 132 times in the sham injection group; this difference was also statistically significant.

The steroid and sham injection groups were similar in terms of demographics, and all patients in both groups were treated with a proton pump inhibitor and underwent gradual dilation of the stricture using fluoroscopically-assisted balloon dilation over a guidewire every 4-6 weeks.

Drug Interaction Warning

Rifampin should not be given along with ritonavir-boosted saquinavir as part of combination antiretroviral therapy for HIV infection, according to the Food and Drug Administration and the drug's maker, Roche Laboratories Inc.

Drug-induced hepatocellular toxicity occurred in 11 of 28 healthy volunteers in a randomized, open-label, phase I trial of rifampin 600 mg once daily given with ritonavir 100 mg/saquinavir 1,000 mg twice daily. Transaminase elevations more than 20 times the upper limit of normal were noted. The study was terminated, and after drug discontinuation, liver function tests in all affected subjects returned to normal. Roche is working with the FDA to make appropriate changes to the package inserts.

Anthrax Vaccine Authorization

Under an FDA Emergency Use Authorization (EUA), adults aged 18-65 years who are at increased risk of exposure to inhalational anthrax due to anthrax attack—as determined by the Department of Defense (DOD)—are now eligible to receive Anthrax Vaccine Adsorbed (AVA) for prevention of the disease.

The FDA issued the EAU as requested by the DOD, which determined that there is significant potential for a military emergency involving a heightened risk to military forces associated with an anthrax attack. This is the first time the EAU authority is being used, and it is required for the use of AVA, because the use of the vaccine for prevention of inhalation anthrax is currently considered unapproved.

In response to a lawsuit in 2003 protesting the DOD's Anthrax Vaccine Immunization Program, the U.S. District Court for the District of Columbia issued a preliminary injunction barring AVA inoculations except in the case of informed consent or a presidential waiver of the informed consent requirement.

Although the injunction was lifted in January 2004, the court remanded the FDA's final rule and final order allowing the injunction to be lifted—effectively reinstating the injunction—to allow for reconsideration following an appropriate notice and comment period. That 90-day comment period began on Dec. 29.

Black Women and HIV

Black women account for the majority of new cases of HIV and AIDS in U.S. women, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher in black than in white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV-positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication, according to the CDC.

MRSA Clone Tackles Athletes

An outbreak of skin abscesses among football players on the St. Louis Rams team was caused by an emerging, community-associated clone of methicillin-resistant Staphylococcus aureus, Sophia V. Kazakova, M.D., of the CDC in Atlanta, and her colleagues reported.

During the 2003 football season, eight MRSA infections leading to large abscesses that required surgical intervention occurred in 5 of the 58 team members. All of the infections occurred at turf-abrasion sites, and they were significantly associated with playing lineman or linebacker positions, suggesting that person-to-person contact plays a role in transmission (N. Engl. J. Med. 2005;352:468-75).

The pulsed-field gel electrophoresis patterns of MRSA from competing teams and community-associated cases were indistinguishable from those of the Rams' MRSA, the investigators said, noting that the clone may be widely distributed in the community.

The CDC has begun population-based surveillance in several parts of the United States to help characterize emergence of MRSA in the community and guide public health interventions, they noted.

Drug Interaction Warning

Rifampin should not be given along with ritonavir-boosted saquinavir as part of combination antiretroviral therapy for HIV infection, according to the Food and Drug Administration and the drug's maker, Roche Laboratories Inc.

Drug-induced hepatocellular toxicity occurred in 11 of 28 healthy volunteers in a randomized, open-label, phase I trial of rifampin 600 mg once daily given with ritonavir 100 mg/saquinavir 1,000 mg twice daily. Transaminase elevations more than 20 times the upper limit of normal were noted. The study was terminated, and after drug discontinuation, liver function tests in all affected subjects returned to normal. Roche is working with the FDA to make appropriate changes to the package inserts.

Anthrax Vaccine Authorization

Under an FDA Emergency Use Authorization (EUA), adults aged 18-65 years who are at increased risk of exposure to inhalational anthrax due to anthrax attack—as determined by the Department of Defense (DOD)—are now eligible to receive Anthrax Vaccine Adsorbed (AVA) for prevention of the disease.

The FDA issued the EAU as requested by the DOD, which determined that there is significant potential for a military emergency involving a heightened risk to military forces associated with an anthrax attack. This is the first time the EAU authority is being used, and it is required for the use of AVA, because the use of the vaccine for prevention of inhalation anthrax is currently considered unapproved.

In response to a lawsuit in 2003 protesting the DOD's Anthrax Vaccine Immunization Program, the U.S. District Court for the District of Columbia issued a preliminary injunction barring AVA inoculations except in the case of informed consent or a presidential waiver of the informed consent requirement.

Although the injunction was lifted in January 2004, the court remanded the FDA's final rule and final order allowing the injunction to be lifted—effectively reinstating the injunction—to allow for reconsideration following an appropriate notice and comment period. That 90-day comment period began on Dec. 29.

Black Women and HIV

Black women account for the majority of new cases of HIV and AIDS in U.S. women, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher in black than in white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV-positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication, according to the CDC.

MRSA Clone Tackles Athletes

An outbreak of skin abscesses among football players on the St. Louis Rams team was caused by an emerging, community-associated clone of methicillin-resistant Staphylococcus aureus, Sophia V. Kazakova, M.D., of the CDC in Atlanta, and her colleagues reported.

During the 2003 football season, eight MRSA infections leading to large abscesses that required surgical intervention occurred in 5 of the 58 team members. All of the infections occurred at turf-abrasion sites, and they were significantly associated with playing lineman or linebacker positions, suggesting that person-to-person contact plays a role in transmission (N. Engl. J. Med. 2005;352:468-75).

The pulsed-field gel electrophoresis patterns of MRSA from competing teams and community-associated cases were indistinguishable from those of the Rams' MRSA, the investigators said, noting that the clone may be widely distributed in the community.

The CDC has begun population-based surveillance in several parts of the United States to help characterize emergence of MRSA in the community and guide public health interventions, they noted.

Drug Interaction Warning

Rifampin should not be given along with ritonavir-boosted saquinavir as part of combination antiretroviral therapy for HIV infection, according to the Food and Drug Administration and the drug's maker, Roche Laboratories Inc.

Drug-induced hepatocellular toxicity occurred in 11 of 28 healthy volunteers in a randomized, open-label, phase I trial of rifampin 600 mg once daily given with ritonavir 100 mg/saquinavir 1,000 mg twice daily. Transaminase elevations more than 20 times the upper limit of normal were noted. The study was terminated, and after drug discontinuation, liver function tests in all affected subjects returned to normal. Roche is working with the FDA to make appropriate changes to the package inserts.

Anthrax Vaccine Authorization

Under an FDA Emergency Use Authorization (EUA), adults aged 18-65 years who are at increased risk of exposure to inhalational anthrax due to anthrax attack—as determined by the Department of Defense (DOD)—are now eligible to receive Anthrax Vaccine Adsorbed (AVA) for prevention of the disease.

The FDA issued the EAU as requested by the DOD, which determined that there is significant potential for a military emergency involving a heightened risk to military forces associated with an anthrax attack. This is the first time the EAU authority is being used, and it is required for the use of AVA, because the use of the vaccine for prevention of inhalation anthrax is currently considered unapproved.

In response to a lawsuit in 2003 protesting the DOD's Anthrax Vaccine Immunization Program, the U.S. District Court for the District of Columbia issued a preliminary injunction barring AVA inoculations except in the case of informed consent or a presidential waiver of the informed consent requirement.

Although the injunction was lifted in January 2004, the court remanded the FDA's final rule and final order allowing the injunction to be lifted—effectively reinstating the injunction—to allow for reconsideration following an appropriate notice and comment period. That 90-day comment period began on Dec. 29.

Black Women and HIV

Black women account for the majority of new cases of HIV and AIDS in U.S. women, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher in black than in white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV-positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication, according to the CDC.

MRSA Clone Tackles Athletes

An outbreak of skin abscesses among football players on the St. Louis Rams team was caused by an emerging, community-associated clone of methicillin-resistant Staphylococcus aureus, Sophia V. Kazakova, M.D., of the CDC in Atlanta, and her colleagues reported.

During the 2003 football season, eight MRSA infections leading to large abscesses that required surgical intervention occurred in 5 of the 58 team members. All of the infections occurred at turf-abrasion sites, and they were significantly associated with playing lineman or linebacker positions, suggesting that person-to-person contact plays a role in transmission (N. Engl. J. Med. 2005;352:468-75).

The pulsed-field gel electrophoresis patterns of MRSA from competing teams and community-associated cases were indistinguishable from those of the Rams' MRSA, the investigators said, noting that the clone may be widely distributed in the community.

The CDC has begun population-based surveillance in several parts of the United States to help characterize emergence of MRSA in the community and guide public health interventions, they noted.

ATLANTA—The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%). About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites. They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%) Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were comparable in American Indians and whites. All cardiovascular risk factors were similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston were struck by the high prevalence of cardiovascular risk factors in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease. Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those with hypertension but no diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those with both diabetes and hypertension had the highest prevalence of ischemic heart disease (20%), reported Nilka Rios Burrows of the Centers for Disease Control and Prevention, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

ATLANTA—The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%). About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites. They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%) Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were comparable in American Indians and whites. All cardiovascular risk factors were similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston were struck by the high prevalence of cardiovascular risk factors in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease. Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those with hypertension but no diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those with both diabetes and hypertension had the highest prevalence of ischemic heart disease (20%), reported Nilka Rios Burrows of the Centers for Disease Control and Prevention, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

ATLANTA—The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%). About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites. They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%) Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were comparable in American Indians and whites. All cardiovascular risk factors were similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston were struck by the high prevalence of cardiovascular risk factors in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease. Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those with hypertension but no diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those with both diabetes and hypertension had the highest prevalence of ischemic heart disease (20%), reported Nilka Rios Burrows of the Centers for Disease Control and Prevention, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

FAJARDO, P.R. — A “multiple simultaneous procedures” approach to surgical management of upper limb cerebral palsy improves function and lessens deformity, Bruce R. Johnstone, M.D., said at the annual meeting of the American Association for Hand Surgery.

The technique involves the release, lengthening, or paralysis of deforming spastic muscles, as well as tendon transfers and joint stabilizations.

It is used to help improve the patient's appearance and the patient's ability to perform tasks of daily living such as dressing and proper hygiene, said Dr. Johnstone of Royal Children's Hospital, Melbourne (Australia).

A phone survey of 48 patients (or their caretakers) who had the surgery between 1992 and 2001 for upper limb spasticity showed that 41 (85%) were satisfied with the outcomes and felt the surgery was worthwhile.

Based on the 0–8 point House scale, median function level increased significantly from 2 points before the surgery to 4 points after the surgery.

Based on a 0- to 4-point cosmesis scale that was created for the study, cosmesis increased significantly from a median of 1 point to 3 points.

Scores for patient hygiene and the ability to dress oneself also increased significantly, Dr. Johnstone said.

The findings may be useful in counseling patients and their caretakers about potential outcomes following surgery, he added.

FAJARDO, P.R. — A “multiple simultaneous procedures” approach to surgical management of upper limb cerebral palsy improves function and lessens deformity, Bruce R. Johnstone, M.D., said at the annual meeting of the American Association for Hand Surgery.

The technique involves the release, lengthening, or paralysis of deforming spastic muscles, as well as tendon transfers and joint stabilizations.

It is used to help improve the patient's appearance and the patient's ability to perform tasks of daily living such as dressing and proper hygiene, said Dr. Johnstone of Royal Children's Hospital, Melbourne (Australia).

A phone survey of 48 patients (or their caretakers) who had the surgery between 1992 and 2001 for upper limb spasticity showed that 41 (85%) were satisfied with the outcomes and felt the surgery was worthwhile.

Based on the 0–8 point House scale, median function level increased significantly from 2 points before the surgery to 4 points after the surgery.

Based on a 0- to 4-point cosmesis scale that was created for the study, cosmesis increased significantly from a median of 1 point to 3 points.

Scores for patient hygiene and the ability to dress oneself also increased significantly, Dr. Johnstone said.

The findings may be useful in counseling patients and their caretakers about potential outcomes following surgery, he added.

FAJARDO, P.R. — A “multiple simultaneous procedures” approach to surgical management of upper limb cerebral palsy improves function and lessens deformity, Bruce R. Johnstone, M.D., said at the annual meeting of the American Association for Hand Surgery.

The technique involves the release, lengthening, or paralysis of deforming spastic muscles, as well as tendon transfers and joint stabilizations.

It is used to help improve the patient's appearance and the patient's ability to perform tasks of daily living such as dressing and proper hygiene, said Dr. Johnstone of Royal Children's Hospital, Melbourne (Australia).

A phone survey of 48 patients (or their caretakers) who had the surgery between 1992 and 2001 for upper limb spasticity showed that 41 (85%) were satisfied with the outcomes and felt the surgery was worthwhile.

Based on the 0–8 point House scale, median function level increased significantly from 2 points before the surgery to 4 points after the surgery.

Based on a 0- to 4-point cosmesis scale that was created for the study, cosmesis increased significantly from a median of 1 point to 3 points.

Scores for patient hygiene and the ability to dress oneself also increased significantly, Dr. Johnstone said.

The findings may be useful in counseling patients and their caretakers about potential outcomes following surgery, he added.

BAL HARBOUR, FLA.— Concentrate on Escherichia coli susceptibility when selecting therapy for initial and first recurrent urinary tract infections in children, Sarah Long, M.D., advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

About 95% of initial UTIs are caused by E. coli, as are most first recurrences, said Dr. Long, chief of the section of infectious disease at Christopher. St's Hospital for Children, Philadelphia.

Other causes of the UTIs generally result from abnormal circumstances, such as dysfunctional voiding, she noted.

Antibiotic resistance is an increasing problem in the treatment of UTIs, so keep this in mind when selecting a drug.

Only about 30% of cases are susceptible to ampicillin and amoxicillin, so these drugs are “off the list,” according to Dr. Long.

Trimethoprim-sulfamethoxazole is also on its way out; only about 50%-80% of cases are susceptible to this treatment, depending on the geographical area.

“I think this is fading as a first drug [for UTIs],” she said.

First-generation cephalosporins, such as cephalexin, and second-generation cephalosporins, such as cefuroxime, remain good choices for treatment, with susceptibility ranging from 95% to 100%.

Third-generation cephalosporins should not be used first for a UTI, Dr. Long stated.

BAL HARBOUR, FLA.— Concentrate on Escherichia coli susceptibility when selecting therapy for initial and first recurrent urinary tract infections in children, Sarah Long, M.D., advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

About 95% of initial UTIs are caused by E. coli, as are most first recurrences, said Dr. Long, chief of the section of infectious disease at Christopher. St's Hospital for Children, Philadelphia.

Other causes of the UTIs generally result from abnormal circumstances, such as dysfunctional voiding, she noted.

Antibiotic resistance is an increasing problem in the treatment of UTIs, so keep this in mind when selecting a drug.

Only about 30% of cases are susceptible to ampicillin and amoxicillin, so these drugs are “off the list,” according to Dr. Long.

Trimethoprim-sulfamethoxazole is also on its way out; only about 50%-80% of cases are susceptible to this treatment, depending on the geographical area.

“I think this is fading as a first drug [for UTIs],” she said.

First-generation cephalosporins, such as cephalexin, and second-generation cephalosporins, such as cefuroxime, remain good choices for treatment, with susceptibility ranging from 95% to 100%.

Third-generation cephalosporins should not be used first for a UTI, Dr. Long stated.

BAL HARBOUR, FLA.— Concentrate on Escherichia coli susceptibility when selecting therapy for initial and first recurrent urinary tract infections in children, Sarah Long, M.D., advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

About 95% of initial UTIs are caused by E. coli, as are most first recurrences, said Dr. Long, chief of the section of infectious disease at Christopher. St's Hospital for Children, Philadelphia.

Other causes of the UTIs generally result from abnormal circumstances, such as dysfunctional voiding, she noted.

Antibiotic resistance is an increasing problem in the treatment of UTIs, so keep this in mind when selecting a drug.

Only about 30% of cases are susceptible to ampicillin and amoxicillin, so these drugs are “off the list,” according to Dr. Long.

Trimethoprim-sulfamethoxazole is also on its way out; only about 50%-80% of cases are susceptible to this treatment, depending on the geographical area.

“I think this is fading as a first drug [for UTIs],” she said.

First-generation cephalosporins, such as cephalexin, and second-generation cephalosporins, such as cefuroxime, remain good choices for treatment, with susceptibility ranging from 95% to 100%.

Third-generation cephalosporins should not be used first for a UTI, Dr. Long stated.

ORLANDO, FLA. — Pregnancy does not cause relapse in patients with inflammatory bowel disease, and standard IBD treatments during pregnancy do not increase the risk of adverse fetal outcomes, a prospective case-control study suggests.

The findings of the 20-year study may give some peace of mind to the many women with IBD who are concerned about the effects of treatment on their fetus, and about the effects of pregnancy on the course of their disease. Until now, these women have had little to go on; the data regarding treatment effects and pregnancy outcomes in IBD have been scant and based only on cohort studies and registry data, Flavio M. Habal, M.D., said at the annual meeting of the American College of Gastroenterology.

He compared outcomes in 138 women with IBD who gave birth to a total of 174 infants over the course of the study, 83 case-matched nonpregnant controls with IBD, and 100 healthy pregnant controls. IBD relapses occurred in 18% of the case patients, compared with 23% of the control patients with IBD. The difference was not statistically significant, said Dr. Habal of the University of Toronto.

Furthermore, the relapse rate was significantly higher in the 50 case patients who were not on IBD maintenance therapy, compared with those who were on maintenance therapy (34% vs. 10%). Treatments used by case patients were oral 5-aminosalycilic acid (5-ASA) used by 58 patients, rectal 5-ASA (10 patients), prednisone (47 patients), and azathioprine (9 patients), he noted.

As for fetal outcomes, the mean birth weight of babies in the case patient group (3,210 g) was similar to the mean birth weight of babies in the healthy control patients (3,215 g), and the mean birth weight among babies of treated case patients (3,328 g) was significantly greater than the mean birth weight among babies of the untreated case patients (3,020 g).

Congenital anomalies occurred in fewer than 2% of the 174 babies in the case patient group, and in a comparable 4% of the 100 babies in the healthy pregnant controls.

Of note is that there were no relapses or congenital anomalies among the nine case patients treated with azathioprine, Dr. Habal said.

ORLANDO, FLA. — Pregnancy does not cause relapse in patients with inflammatory bowel disease, and standard IBD treatments during pregnancy do not increase the risk of adverse fetal outcomes, a prospective case-control study suggests.

The findings of the 20-year study may give some peace of mind to the many women with IBD who are concerned about the effects of treatment on their fetus, and about the effects of pregnancy on the course of their disease. Until now, these women have had little to go on; the data regarding treatment effects and pregnancy outcomes in IBD have been scant and based only on cohort studies and registry data, Flavio M. Habal, M.D., said at the annual meeting of the American College of Gastroenterology.

He compared outcomes in 138 women with IBD who gave birth to a total of 174 infants over the course of the study, 83 case-matched nonpregnant controls with IBD, and 100 healthy pregnant controls. IBD relapses occurred in 18% of the case patients, compared with 23% of the control patients with IBD. The difference was not statistically significant, said Dr. Habal of the University of Toronto.

Furthermore, the relapse rate was significantly higher in the 50 case patients who were not on IBD maintenance therapy, compared with those who were on maintenance therapy (34% vs. 10%). Treatments used by case patients were oral 5-aminosalycilic acid (5-ASA) used by 58 patients, rectal 5-ASA (10 patients), prednisone (47 patients), and azathioprine (9 patients), he noted.

As for fetal outcomes, the mean birth weight of babies in the case patient group (3,210 g) was similar to the mean birth weight of babies in the healthy control patients (3,215 g), and the mean birth weight among babies of treated case patients (3,328 g) was significantly greater than the mean birth weight among babies of the untreated case patients (3,020 g).

Congenital anomalies occurred in fewer than 2% of the 174 babies in the case patient group, and in a comparable 4% of the 100 babies in the healthy pregnant controls.

Of note is that there were no relapses or congenital anomalies among the nine case patients treated with azathioprine, Dr. Habal said.

ORLANDO, FLA. — Pregnancy does not cause relapse in patients with inflammatory bowel disease, and standard IBD treatments during pregnancy do not increase the risk of adverse fetal outcomes, a prospective case-control study suggests.

The findings of the 20-year study may give some peace of mind to the many women with IBD who are concerned about the effects of treatment on their fetus, and about the effects of pregnancy on the course of their disease. Until now, these women have had little to go on; the data regarding treatment effects and pregnancy outcomes in IBD have been scant and based only on cohort studies and registry data, Flavio M. Habal, M.D., said at the annual meeting of the American College of Gastroenterology.

He compared outcomes in 138 women with IBD who gave birth to a total of 174 infants over the course of the study, 83 case-matched nonpregnant controls with IBD, and 100 healthy pregnant controls. IBD relapses occurred in 18% of the case patients, compared with 23% of the control patients with IBD. The difference was not statistically significant, said Dr. Habal of the University of Toronto.

Furthermore, the relapse rate was significantly higher in the 50 case patients who were not on IBD maintenance therapy, compared with those who were on maintenance therapy (34% vs. 10%). Treatments used by case patients were oral 5-aminosalycilic acid (5-ASA) used by 58 patients, rectal 5-ASA (10 patients), prednisone (47 patients), and azathioprine (9 patients), he noted.

As for fetal outcomes, the mean birth weight of babies in the case patient group (3,210 g) was similar to the mean birth weight of babies in the healthy control patients (3,215 g), and the mean birth weight among babies of treated case patients (3,328 g) was significantly greater than the mean birth weight among babies of the untreated case patients (3,020 g).

Congenital anomalies occurred in fewer than 2% of the 174 babies in the case patient group, and in a comparable 4% of the 100 babies in the healthy pregnant controls.

Of note is that there were no relapses or congenital anomalies among the nine case patients treated with azathioprine, Dr. Habal said.

ATLANTA — Substance abuse is pervasive among gay men and is so intricately intertwined with epidemics of depression, partner abuse, and childhood sexual abuse that adequately addressing one issue requires attention to the others as well, said Ronald Stall, Ph.D., chief of prevention research for the division of HIV/AIDS prevention at the Centers for Disease Control and Prevention, Atlanta.

A population-based telephone-survey of nearly 3,000 gay men living in urban areas across the United States showed that in the prior 6 months, 90% of respondents had used alcohol, 50% had smoked marijuana, nearly 20% had used cocaine, 10% had used crack cocaine, and 10% had used methamphetamine. About 1% of respondents were current intravenous drug users.

Gay men on the East and West Coasts favored different drugs. Those on the West Coast preferred methamphetamine; those on the East Coast were more likely to smoke marijuana. “But by and large, they were using [the drugs] for the same purposes,” Dr. Stall said at a conference jointly sponsored by the National Association of Addiction Treatment Providers and the Medical College of Georgia.

The survey findings debunk old, poorly constructed studies suggested that one in three was alcoholic, but that oft-quoted figure is inflated, Dr. Stall said.

Current alcoholism appears to be present in 10% of gay men, which is similar to the rate in a national sample of about 20,000 people from the general population.

About 1 in 10 gay men in the current study reported frequent heavy alcohol use (five or more drinks at one sitting at least once each week), and the same number reported three or more alcohol-related problems, which is diagnostic for problem drinking. Drug use was more prevalent. One in five reported drug use at least once each week or the use of three or more different drugs in the last 6 months, he said.

Compared with the general population sample, the gay male population sample had a 4-fold increase in marijuana use, a 7-fold increase in cocaine use, and a 10-fold increase in amphetamine use.

Data consistently show that drug use—particularly intravenous drug use—is associated with about a 40% increased risk of HIV infection. It appears that men who do not use intravenous drugs but who have high rates of other substance abuse have an equally high risk of HIV infection. Numerous studies have shown that substance use and high-risk sex are closely linked, he said.

In the current survey, substance use, childhood sex abuse, partner violence, and major depression emerged as interrelated issues that also are closely linked. Major depression and partner violence predicted multiple drug use and childhood sex abuse, and multiple drug use, childhood sex abuse, and partner violence were predictors of major depression.

“We have at least four epidemics going on among gay men that are associated with each other and making each other worse. Dealing with only one at a time may not be as effective as if we try to address them all,” he said.

In treating a patient with a substance use disorder, for example, the ability to achieve sobriety might be impaired if a history of childhood sexual abuse or major depression is not addressed simultaneously. Effectively addressing these matters in the gay male population requires teamwork on the part of organizations attempting to resolve each of these problems in isolation from the others.

The four epidemics should also be considered in the context of HIV risk. Two solid trials have suggested that substance abuse treatment is effective for reducing HIV risk-taking behaviors, which raises the possibility that substance abuse treatment equals HIV prevention.

ATLANTA — Substance abuse is pervasive among gay men and is so intricately intertwined with epidemics of depression, partner abuse, and childhood sexual abuse that adequately addressing one issue requires attention to the others as well, said Ronald Stall, Ph.D., chief of prevention research for the division of HIV/AIDS prevention at the Centers for Disease Control and Prevention, Atlanta.

A population-based telephone-survey of nearly 3,000 gay men living in urban areas across the United States showed that in the prior 6 months, 90% of respondents had used alcohol, 50% had smoked marijuana, nearly 20% had used cocaine, 10% had used crack cocaine, and 10% had used methamphetamine. About 1% of respondents were current intravenous drug users.

Gay men on the East and West Coasts favored different drugs. Those on the West Coast preferred methamphetamine; those on the East Coast were more likely to smoke marijuana. “But by and large, they were using [the drugs] for the same purposes,” Dr. Stall said at a conference jointly sponsored by the National Association of Addiction Treatment Providers and the Medical College of Georgia.

The survey findings debunk old, poorly constructed studies suggested that one in three was alcoholic, but that oft-quoted figure is inflated, Dr. Stall said.

Current alcoholism appears to be present in 10% of gay men, which is similar to the rate in a national sample of about 20,000 people from the general population.

About 1 in 10 gay men in the current study reported frequent heavy alcohol use (five or more drinks at one sitting at least once each week), and the same number reported three or more alcohol-related problems, which is diagnostic for problem drinking. Drug use was more prevalent. One in five reported drug use at least once each week or the use of three or more different drugs in the last 6 months, he said.

Compared with the general population sample, the gay male population sample had a 4-fold increase in marijuana use, a 7-fold increase in cocaine use, and a 10-fold increase in amphetamine use.

Data consistently show that drug use—particularly intravenous drug use—is associated with about a 40% increased risk of HIV infection. It appears that men who do not use intravenous drugs but who have high rates of other substance abuse have an equally high risk of HIV infection. Numerous studies have shown that substance use and high-risk sex are closely linked, he said.

In the current survey, substance use, childhood sex abuse, partner violence, and major depression emerged as interrelated issues that also are closely linked. Major depression and partner violence predicted multiple drug use and childhood sex abuse, and multiple drug use, childhood sex abuse, and partner violence were predictors of major depression.

“We have at least four epidemics going on among gay men that are associated with each other and making each other worse. Dealing with only one at a time may not be as effective as if we try to address them all,” he said.

In treating a patient with a substance use disorder, for example, the ability to achieve sobriety might be impaired if a history of childhood sexual abuse or major depression is not addressed simultaneously. Effectively addressing these matters in the gay male population requires teamwork on the part of organizations attempting to resolve each of these problems in isolation from the others.

The four epidemics should also be considered in the context of HIV risk. Two solid trials have suggested that substance abuse treatment is effective for reducing HIV risk-taking behaviors, which raises the possibility that substance abuse treatment equals HIV prevention.

ATLANTA — Substance abuse is pervasive among gay men and is so intricately intertwined with epidemics of depression, partner abuse, and childhood sexual abuse that adequately addressing one issue requires attention to the others as well, said Ronald Stall, Ph.D., chief of prevention research for the division of HIV/AIDS prevention at the Centers for Disease Control and Prevention, Atlanta.

A population-based telephone-survey of nearly 3,000 gay men living in urban areas across the United States showed that in the prior 6 months, 90% of respondents had used alcohol, 50% had smoked marijuana, nearly 20% had used cocaine, 10% had used crack cocaine, and 10% had used methamphetamine. About 1% of respondents were current intravenous drug users.

Gay men on the East and West Coasts favored different drugs. Those on the West Coast preferred methamphetamine; those on the East Coast were more likely to smoke marijuana. “But by and large, they were using [the drugs] for the same purposes,” Dr. Stall said at a conference jointly sponsored by the National Association of Addiction Treatment Providers and the Medical College of Georgia.

The survey findings debunk old, poorly constructed studies suggested that one in three was alcoholic, but that oft-quoted figure is inflated, Dr. Stall said.

Current alcoholism appears to be present in 10% of gay men, which is similar to the rate in a national sample of about 20,000 people from the general population.

About 1 in 10 gay men in the current study reported frequent heavy alcohol use (five or more drinks at one sitting at least once each week), and the same number reported three or more alcohol-related problems, which is diagnostic for problem drinking. Drug use was more prevalent. One in five reported drug use at least once each week or the use of three or more different drugs in the last 6 months, he said.

Compared with the general population sample, the gay male population sample had a 4-fold increase in marijuana use, a 7-fold increase in cocaine use, and a 10-fold increase in amphetamine use.

Data consistently show that drug use—particularly intravenous drug use—is associated with about a 40% increased risk of HIV infection. It appears that men who do not use intravenous drugs but who have high rates of other substance abuse have an equally high risk of HIV infection. Numerous studies have shown that substance use and high-risk sex are closely linked, he said.

In the current survey, substance use, childhood sex abuse, partner violence, and major depression emerged as interrelated issues that also are closely linked. Major depression and partner violence predicted multiple drug use and childhood sex abuse, and multiple drug use, childhood sex abuse, and partner violence were predictors of major depression.

“We have at least four epidemics going on among gay men that are associated with each other and making each other worse. Dealing with only one at a time may not be as effective as if we try to address them all,” he said.

In treating a patient with a substance use disorder, for example, the ability to achieve sobriety might be impaired if a history of childhood sexual abuse or major depression is not addressed simultaneously. Effectively addressing these matters in the gay male population requires teamwork on the part of organizations attempting to resolve each of these problems in isolation from the others.

The four epidemics should also be considered in the context of HIV risk. Two solid trials have suggested that substance abuse treatment is effective for reducing HIV risk-taking behaviors, which raises the possibility that substance abuse treatment equals HIV prevention.

ATLANTA — The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%).

About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster presented at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites.

They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%), Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were found to be comparable in American Indians and whites. All cardiovascular risk factors were found to be similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston said that they were struck by the high prevalence of cardiovascular risk factors found in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease.

Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those individuals with hypertension but without diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those individuals with both diabetes and hypertension were found to have the highest prevalence (20%), reported Nilka Rios Burrows of the CDC, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

ATLANTA — The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%).

About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster presented at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites.

They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%), Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were found to be comparable in American Indians and whites. All cardiovascular risk factors were found to be similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston said that they were struck by the high prevalence of cardiovascular risk factors found in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease.

Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those individuals with hypertension but without diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those individuals with both diabetes and hypertension were found to have the highest prevalence (20%), reported Nilka Rios Burrows of the CDC, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

ATLANTA — The prevalence of cardiovascular risk factors and cardiovascular disease is alarmingly high and continues to rise in Native Americans, according to several reports at a prevention conference on heart disease and stroke sponsored by the Centers for Disease Control and Prevention.

In one study of adult Native Americans (defined as American Indians and Alaska Natives) from Montana who took part in an annual telephone survey, significant increases were seen between 1999 and 2003 in the proportion reporting diabetes (12% vs. 16%), hypertension (26% vs. 34%), high cholesterol (23% vs. 30%), and obesity (34% vs. 39%).

About 1,000 adults completed the survey in each of the four study years, Carrie S. Oser reported in a poster presented at the meeting.

After adjustment for age, sex, and survey year, the increases in the proportion reporting hypertension, high cholesterol, and obesity remained significant, said Ms. Oser of the Montana Department of Public Health and Human Services in Helena.

The prevalence of cardiovascular disease increased slightly from 10% to 11% over the course of the study, and smoking rates dropped slightly from 38% to 36%, although they remained high.

In another study of Native Americans in North Carolina, which has the eighth-largest Native American population in the United States, age-adjusted rates of cardiovascular risk factor prevalence were compared with those of North Carolina whites and African Americans.

The 285 Native Americans studied in 2002 and the 230 studied in 2003 had higher rates of hypertension (40% vs. 27%), obesity (33% vs. 21%), and diabetes (14% vs. 7%) than did whites.

They also were less likely than whites to engage in leisure-time physical activity (66% vs. 76%) and to engage in the recommended amount of physical activity for cardiovascular health (29% vs. 40%), and they were less likely to eat five or more servings of fruits and vegetables daily (19% vs. 25%), Sara L. Huston, Ph.D., reported in a poster.

Smoking and high cholesterol rates in this study were found to be comparable in American Indians and whites. All cardiovascular risk factors were found to be similar in Native Americans and African Americans, she said.

Both Ms. Oser and Dr. Huston said that they were struck by the high prevalence of cardiovascular risk factors found in Native Americans; the prevalence in this population had been largely unknown, noted Dr. Huston, who concluded that culturally appropriate intervention and prevention programs are needed to address the problem.

The need for such programs also was highlighted in another poster showing that with the rise in the prevalence of diabetes and hypertension in Native Americans is a likely risk in the prevalence of ischemic heart disease.

Based on 2002 ambulatory care data from the Indian Health Service, the age-adjusted prevalence of ischemic heart disease among Native Americans and Native Alaskans aged 45 years and older was estimated to be nearly three times higher in those with diabetes than in those without diabetes (17% vs. 6%).

Those individuals with hypertension but without diabetes had a higher age-adjusted prevalence of ischemic heart disease than did those with diabetes alone (13% vs. 7%). Those individuals with both diabetes and hypertension were found to have the highest prevalence (20%), reported Nilka Rios Burrows of the CDC, Atlanta.

These rates are likely to rise in tandem with the increasing prevalence of diabetes and other cardiovascular risk factors in Native Americans; interventions to control blood glucose, lipid, and blood pressure levels would benefit this population, she said.

ATLANTA – Eating disorders and substance abuse often go hand in hand, and treatment of patients with both is often improved when there is a focus on body reclamation, Adrienne Ressler said at a conference jointly sponsored by the National Association of Addiction Treatment Professionals and the Medical College of Georgia.

Studies suggest that the prevalence of substance abuse in patients with eating disorders is eight times greater than in the general population and that the prevalence of eating disorders in substance abuse patients is five times greater than the general population, said Ms. Ressler, national training director at the Renfrew Center in Coconut Creek, Fla.

She noted that bulimia patients–who are more likely than anorexic patients to use drugs and alcohol–have higher suicide rates when they have comorbid substance abuse.

Eating disorders often appear to develop after a substance use disorder is treated, “but I'm not sure that the eating disorder wasn't always there … that the drive for thinness did not put some of these women on a path that got them hooked,” she said.

Drugs used to suppress appetite–alcohol, amphetamines, cocaine, diet pills, caffeine, and nicotine–are addictive, and some addictive drugs, such as laxatives and alcohol, can also be used to induce purging, she explained.

Regardless of which disorder comes first, or if the two are linked, concurrent treatment can be beneficial and is the current trend, Ms. Ressler said.

In her experience treating women, when the two disorders aren't treated together, one tends to get worse while the other improves.

A key part of treatment for women involves reclaiming the body.

This may seem paradoxical for eating disorder patients who are constantly obsessed with their bodies, but rather than living in their bodies, they are living in a world of images and recurring voices telling them how their bodies should look, Ms. Ressler explained.

It is important for them to take back the control, and doing so requires that they identify what they are longing for. Integrated mind-body medicine can be useful for this, she commented.

Massage, meditation, and “drumming” have been shown to be useful in these patients. As an adjunct to psychotherapy, meditation can promote general well-being, reduce anxiety and pain, and promote self-awareness and self-regulation.

This is important because there is growing evidence that compulsive eaters and chronic dieters are disengaged from internal self-regulatory systems of control and are overly influenced by external cues, belief, systems, and emotional signals, Ms. Ressler noted.

In one pilot study, meditation was used to reduce stress, and this lowered binge-eating episodes from 4 to 1.25 per week, she said.

In another study, massage performed on bulimia patients twice weekly for 5 weeks in conjunction with their therapy had an immediate beneficial effect on anxiety, depression, levels of serotonin and dopamine, and body image.

Rhythmic therapy, such as drumming, also appears to have soothing effects. It has been suggested that drumming can increase body awareness, build self-esteem, and strengthen impulse control, she said at the meeting.

These approaches to treatment can be beneficial in patients with eating disorder and substance abuse because the body is the controller in these patients, and they often come to hate their bodies because of that–the body can become the target for self-harm such as burning, skin picking, and self-cutting.

“These patients have an adversarial relationship with the body. … We need to help them calm the body and learn to self-soothe,” Ms. Ressler said.

ATLANTA – Eating disorders and substance abuse often go hand in hand, and treatment of patients with both is often improved when there is a focus on body reclamation, Adrienne Ressler said at a conference jointly sponsored by the National Association of Addiction Treatment Professionals and the Medical College of Georgia.

Studies suggest that the prevalence of substance abuse in patients with eating disorders is eight times greater than in the general population and that the prevalence of eating disorders in substance abuse patients is five times greater than the general population, said Ms. Ressler, national training director at the Renfrew Center in Coconut Creek, Fla.

She noted that bulimia patients–who are more likely than anorexic patients to use drugs and alcohol–have higher suicide rates when they have comorbid substance abuse.

Eating disorders often appear to develop after a substance use disorder is treated, “but I'm not sure that the eating disorder wasn't always there … that the drive for thinness did not put some of these women on a path that got them hooked,” she said.

Drugs used to suppress appetite–alcohol, amphetamines, cocaine, diet pills, caffeine, and nicotine–are addictive, and some addictive drugs, such as laxatives and alcohol, can also be used to induce purging, she explained.

Regardless of which disorder comes first, or if the two are linked, concurrent treatment can be beneficial and is the current trend, Ms. Ressler said.

In her experience treating women, when the two disorders aren't treated together, one tends to get worse while the other improves.

A key part of treatment for women involves reclaiming the body.

This may seem paradoxical for eating disorder patients who are constantly obsessed with their bodies, but rather than living in their bodies, they are living in a world of images and recurring voices telling them how their bodies should look, Ms. Ressler explained.

It is important for them to take back the control, and doing so requires that they identify what they are longing for. Integrated mind-body medicine can be useful for this, she commented.

Massage, meditation, and “drumming” have been shown to be useful in these patients. As an adjunct to psychotherapy, meditation can promote general well-being, reduce anxiety and pain, and promote self-awareness and self-regulation.

This is important because there is growing evidence that compulsive eaters and chronic dieters are disengaged from internal self-regulatory systems of control and are overly influenced by external cues, belief, systems, and emotional signals, Ms. Ressler noted.

In one pilot study, meditation was used to reduce stress, and this lowered binge-eating episodes from 4 to 1.25 per week, she said.

In another study, massage performed on bulimia patients twice weekly for 5 weeks in conjunction with their therapy had an immediate beneficial effect on anxiety, depression, levels of serotonin and dopamine, and body image.

Rhythmic therapy, such as drumming, also appears to have soothing effects. It has been suggested that drumming can increase body awareness, build self-esteem, and strengthen impulse control, she said at the meeting.

These approaches to treatment can be beneficial in patients with eating disorder and substance abuse because the body is the controller in these patients, and they often come to hate their bodies because of that–the body can become the target for self-harm such as burning, skin picking, and self-cutting.

“These patients have an adversarial relationship with the body. … We need to help them calm the body and learn to self-soothe,” Ms. Ressler said.

ATLANTA – Eating disorders and substance abuse often go hand in hand, and treatment of patients with both is often improved when there is a focus on body reclamation, Adrienne Ressler said at a conference jointly sponsored by the National Association of Addiction Treatment Professionals and the Medical College of Georgia.

Studies suggest that the prevalence of substance abuse in patients with eating disorders is eight times greater than in the general population and that the prevalence of eating disorders in substance abuse patients is five times greater than the general population, said Ms. Ressler, national training director at the Renfrew Center in Coconut Creek, Fla.

She noted that bulimia patients–who are more likely than anorexic patients to use drugs and alcohol–have higher suicide rates when they have comorbid substance abuse.

Eating disorders often appear to develop after a substance use disorder is treated, “but I'm not sure that the eating disorder wasn't always there … that the drive for thinness did not put some of these women on a path that got them hooked,” she said.

Drugs used to suppress appetite–alcohol, amphetamines, cocaine, diet pills, caffeine, and nicotine–are addictive, and some addictive drugs, such as laxatives and alcohol, can also be used to induce purging, she explained.

Regardless of which disorder comes first, or if the two are linked, concurrent treatment can be beneficial and is the current trend, Ms. Ressler said.

In her experience treating women, when the two disorders aren't treated together, one tends to get worse while the other improves.

A key part of treatment for women involves reclaiming the body.

This may seem paradoxical for eating disorder patients who are constantly obsessed with their bodies, but rather than living in their bodies, they are living in a world of images and recurring voices telling them how their bodies should look, Ms. Ressler explained.

It is important for them to take back the control, and doing so requires that they identify what they are longing for. Integrated mind-body medicine can be useful for this, she commented.

Massage, meditation, and “drumming” have been shown to be useful in these patients. As an adjunct to psychotherapy, meditation can promote general well-being, reduce anxiety and pain, and promote self-awareness and self-regulation.

This is important because there is growing evidence that compulsive eaters and chronic dieters are disengaged from internal self-regulatory systems of control and are overly influenced by external cues, belief, systems, and emotional signals, Ms. Ressler noted.

In one pilot study, meditation was used to reduce stress, and this lowered binge-eating episodes from 4 to 1.25 per week, she said.

In another study, massage performed on bulimia patients twice weekly for 5 weeks in conjunction with their therapy had an immediate beneficial effect on anxiety, depression, levels of serotonin and dopamine, and body image.

Rhythmic therapy, such as drumming, also appears to have soothing effects. It has been suggested that drumming can increase body awareness, build self-esteem, and strengthen impulse control, she said at the meeting.

These approaches to treatment can be beneficial in patients with eating disorder and substance abuse because the body is the controller in these patients, and they often come to hate their bodies because of that–the body can become the target for self-harm such as burning, skin picking, and self-cutting.

“These patients have an adversarial relationship with the body. … We need to help them calm the body and learn to self-soothe,” Ms. Ressler said.