<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_472"
                     title="Test Allows LMW Heparin Monitoring in Cath Lab (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/PCI/tb/18403?impressionId=1265815583515"
                     
      &lt;p&gt;A novel point-of-care anticoagulation test not yet available in the U.S. allowed more accurate dosing of enoxaparin (Lovenox) prior to cardiac catheterization in a clinical trial, researchers said.&lt;/p&gt;
&lt;p&gt;Patients in whom anticoagulation was insufficient with standard enoxaparin doses were identified with the Hemochron Jr. Hemonox test at a sensitivity of 94.9% (95% CI 91.1% to 97.4%) and specificity of 73.3% (95% CI 67.6% to 78.5%), allowing for needed dosage adjustments before undergoing catheterization and coronary revascularization, reported Johanne Silvain, MD, of Piti&amp;#233;-Salp&amp;#234;tri&amp;#232;re Hospital in Paris, and colleagues.&lt;/p&gt;
&lt;p&gt;&quot;In daily practice, the Hemonox test may be used in the catheterization laboratory to assess the appropriate level of anticoagulation therapy in patients undergoing percutaneous coronary intervention and to avoid the use of unfractionated heparin in addition to enoxaparin, as is still done by some interventionists,&quot; the researchers wrote in the Feb. 16 &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Normally, anticoagulant therapy is started in patients scheduled for catheterization to minimize the risk that the procedure will trigger a thrombotic event.&lt;/p&gt;
&lt;p&gt;Silvain and colleagues explained that low molecular weight heparins such as enoxaparin appear to be safer and at least as effective as unfractionated heparin, but are not widely used.&lt;/p&gt;
&lt;p&gt;&quot;The inability to rapidly monitor the anticoagulant effect of enoxaparin in a similar fashion as the activated clotting time with unfractionated heparin has limited the use of enoxaparin in interventional cardiac procedures,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Past clinical studies have found that most but not all patients achieve target levels of anticoagulation using standard doses of enoxaparin, Silvain and colleagues noted. Excessive anticoagulation increases risk of bleeding, whereas shortfalls raise the likelihood of periprocedural&lt;strong&gt; &lt;/strong&gt;myocardial infarction, pulmonary embolism, and stroke.&lt;/p&gt;
&lt;p&gt;According to Silvain and colleagues, there are currently no good ways to measure the adequacy of enoxaparin dosing at bedside. Activated clotting time is too imprecise with enoxaparin, and chromogenic anti-factor Xa activity requires a laboratory-performed assay, they wrote.&lt;/p&gt;
&lt;p&gt;They evaluated the Hemonox test in 296 unselected patients undergoing catheterization because of cardiac symptoms, of whom 169 went on to percutaneous revascularization or bypass graft surgery.&lt;/p&gt;
&lt;p&gt;The Hemonox test delivers results as a clotting time.&lt;/p&gt;
&lt;p&gt;Enoxaparin was given intravenously in 211 patients, in combination with subcutaneous enoxaparin in 21, only subcutaneously to 64 patients, and the route was unrecorded in the remaining 14.&lt;/p&gt;
&lt;p&gt;Blood samples were drawn immediately after sheath insertion and again 10 minutes later. Samples were tested with Hemonox, a standard assay for activated partial thromboplastin time, and the lab assay for anti-factor Xa activity. The latter served as the &quot;gold standard&quot; reference in the study.&lt;/p&gt;
&lt;p&gt;Insufficient anticoagulation  --  defined as an anti-factor Xa level of less than 0.5 IU/mL  --  was found in 14 patients at the second blood draw. Excessive anticoagulation occurred in only three patients, all of whom had anti-factor Xa levels of 1.9 IU/mL (upper level cutoff 1.8 IU/mL).&lt;/p&gt;
&lt;p&gt;Silvain and colleagues found that the area below the receiver operating characteristic curve for the Hemonox test, for discriminating those individuals with inadequate anticoagulation, was 0.95 relative to the anti-factor Xa assay (95% CI 0.93 to 0.97).&lt;/p&gt;
&lt;p&gt;Using a cutoff of 120 seconds for the Hemonox clotting time to identify inadequate anticoagulation, which maximizes the sensitivity, the results produced a positive predictive value of 73.9% (95% CI 68.7% to 79.0%) and a negative predictive value of 94.8% (95% CI 91.8% to 97.8%).&lt;/p&gt;
&lt;p&gt;A cutoff of 80 seconds reversed the Hemonox test&apos;s performance almost exactly  --  it produced a sensitivity for detecting inadequate anticoagulation of 74.5% and a specificity of 98.5%. Silvain and colleagues explained that, in patients undergoing interventional procedures, &quot;the sensitivity of the bedside test is critical.&quot;&lt;/p&gt;
&lt;p&gt;Activated partial thromboplastin time correlated much more poorly with anti-factor Xa results, the researchers said.&lt;/p&gt;
&lt;p&gt;The Hemonox results paralleled those of the anti-factor Xa assay in important subgroups, including obese patients and the elderly, the researchers reported.&lt;/p&gt;
&lt;p&gt;Two major bleeding events were observed in the study, both in patients with anti-factor Xa levels well within the target range.&lt;/p&gt;
&lt;p&gt;Silvain and colleagues noted that the lack of clinical outcomes as a study endpoint was a limitation, as was the lack of sufficient data to assess the Hemonox test&apos;s effectiveness in measuring excessive anticoagulation.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by International Technidyne Corp., which developed the anticoagulation test.&lt;/p&gt;&lt;p&gt;Study authors reported relationships other than research funding with Pfizer, sanofi-aventis, Astellas, Eli Lilly, Bristol-Myers Squibb, The Medicines Company, Schering-Plough, Merck Sharpe &amp;amp; Dohme, Cordis, and GlaxoSmithKline. They also reported research funding from Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, sanofi-aventis, Eli Lilly, Guerbet Medical, Medtronic, Boston Scientific, Cordis, Stago, and Centocor.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_471"
                     title="Early Pregnancy Determines Late Outcomes (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18405?impressionId=1265815583515"
                     
      &lt;p&gt;Growth of the fetus during the first trimester  --  when essential organ development is completed  --  lays the foundation for important outcomes in pregnancy and early childhood, Dutch researchers found.&lt;/p&gt;
&lt;p&gt;Restricted first-trimester growth appeared to more than double the risk of preterm birth, low birth weight, and small size for gestational age at birth in a prospective study led by Vincent W.V. Jaddoe, MD, PhD, of Erasmus Medical Center in Rotterdam.&lt;/p&gt;
&lt;p&gt;Infants who didn&apos;t grow as much as expected during the first trimester also showed accelerated &quot;catch-up&quot; growth up to their second birthday  --  a well-established risk factor for later metabolic and cardiovascular disease.&lt;/p&gt;
&lt;p&gt;&quot;It could be that growth as early as in the first trimester of pregnancy is associated with disease in adulthood, although longer follow-up studies are necessary to examine this relationship,&quot; the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This and prior studies suggest that women at high risk of problems late in pregnancy could be identifiable in the first trimester, with the potential for trials of screening and early intervention, according to an accompanying editorial by Gordon C.S. Smith, MD, PhD, of the University of Cambridge, England.&lt;/p&gt;
&lt;p&gt;The challenge, Smith wrote, will be to &quot;produce robust screening tests with acceptable levels of detection and prediction, and to identify interventions that are effective in improving outcome when a pregnancy has been identified as high risk.&quot;&lt;/p&gt;
&lt;p&gt;The researchers&apos; population-based, prospective Generation R Study included 1,631 pregnant women in Rotterdam with a known and reliable first day of their last menstrual period and a regular menstrual cycle.&lt;/p&gt;
&lt;p&gt;Fetal crown-to-rump length, measured by ultrasound between the gestational age of 10 weeks 0 days and 13&lt;/p&gt;
&lt;p&gt;weeks 6 days, is typically used to determine gestational age. But in this study it served as the main parameter of first-trimester fetal growth.&lt;/p&gt;
&lt;p&gt;Predictors of restricted fetal growth in multivariate analyses included the following (given as standard deviation growth score): &lt;ul&gt; &lt;li&gt;Younger maternal age (0.10 per 4.68-year standard deviation increase, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) &lt;/li&gt; &lt;li&gt;Higher maternal diastolic blood pressure (&amp;#8722;0.05 per 9.52-mm Hg standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;li&gt;Higher hematocrit level (&amp;#8722;0.07 per 2.50% standard deviation increase, &lt;em&gt;P&lt;/em&gt;=0.02) &lt;/li&gt; &lt;li&gt;Smoking (&amp;#8722;0.13, &lt;em&gt;P&lt;/em&gt;=0.03)&lt;/li&gt; &lt;li&gt;Folic acid supplement use (0.17, &lt;em&gt;P&lt;/em&gt;=0.03) &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;After adjustment for multiple testing, only hematocrit and maternal age remained significant factors, but smoking and nonoptimal use of folic acid supplements together produced a significant reduction in first-trimester fetal growth (SD score &amp;#8722;0.52, 95% CI &amp;#8722;0.78 to &amp;#8722;0.25, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction).&lt;/p&gt;
&lt;p&gt;Higher hematocrit levels may indicate lower circulating plasma volume. That in turn could lead to suboptimal placental perfusion, the researchers suggested as a possible explanation for the importance of this factor.&lt;/p&gt;
&lt;p&gt;The impact on pregnancy outcomes was significant for all adverse birth outcomes assessed. Compared with normal first-trimester fetal growth, growth restriction was associated with the following risks: &lt;ul&gt; &lt;li&gt;2.12-fold higher adjusted odds of preterm birth before 37 weeks&apos; gestation (4.0% versus 7.2%, &lt;em&gt;P&lt;/em&gt;=0.006).&lt;/li&gt; &lt;li&gt;2.42-fold higher adjusted odds of low birth weight, defined as less than 2,500 g or 5 lb 8 oz (3.5% versus 7.5%, &lt;em&gt;P&lt;/em&gt;=0.001).&lt;/li&gt; &lt;li&gt;2.64-fold higher adjusted odds of being small for gestational age at birth, defined as in the lowest 20% (4.0% versus 10.6%, &lt;em&gt;P&lt;/em&gt;=0.001). &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Independent of birth weight, fetal growth restriction in the first trimester accelerated postnatal growth until age 2 years (0.139 standard deviation score increase over two years per standard deviation fetal-crown-to-rump length decrease, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Even though they included only women with reliable menstrual cycles, the authors noted, misclassification of gestational age might still have been an issue, depending on timing of ovulation and implantation.&lt;/p&gt;
&lt;p&gt;&quot;Further studies are needed to assess the associations of first-trimester growth variation on the risks of disease in later childhood and adulthood,&quot; they concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The first phase of the Generation R Study was financially supported by the Erasmus Medical Center, the Erasmus University Rotterdam, and the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;Jaddoe reported receipt of funding from the Netherlands Organization for Health Research.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Smith reported having been a member of preterm labor advisory boards for GlaxoSmithKline. He also reported funding from Cambridge National Institute for Health Research Biomedical Research Centre, Cambridge University Hospitals, NHS Foundation Trust.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_470"
                     title="For-Profit Hospitals Most Likely to Overtreat Dementia Patients (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Geriatrics/Dementia/tb/18402?impressionId=1265815583515"
                     
      Tube-feeding patients with advanced dementia  --  a practice whose effectiveness has been questioned by two widely cited literature reviews  --  is most common in larger hospitals and those run for profit, researchers said.&lt;br&gt;
&lt;br&gt;The odds of a feeding-tube insertion in a hospitalized patient with advanced dementia were about 50% greater when the hospital was larger than 310 beds than in facilities with 100 beds or less, and it was 33% more common in for-profit versus government-owned facilities, reported Joan M. Teno, MD, of Brown University in Providence, R.I., and colleagues.&lt;br&gt;
&lt;br&gt;Hospitals that frequently admitted elderly patients in the last six months of life to their ICUs  --  signifying a pattern of aggressive end-of-life care  --  were also substantially more likely to use tube feeding, the researchers wrote in the Feb. 10 &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;At some 12% of the 2,797 acute-care hospitals included in the analysis, which covered an eight-year period ending in 2007, feeding tubes were never used in patients with advanced dementia.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;In others, however, such patients were intubated for feeding at rates of up to 38.9 per 100 hospitalizations.&lt;/p&gt;
&lt;p&gt;Teno and colleagues suggested that many of these insertions reflect overtreatment. They cited previous research showing that tube feeding &quot;does not improve survival, prevent aspiration pneumonia, heal or prevent decubitus ulcers, or improve other clinical outcomes.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Feeding tube insertion in persons with advanced cognitive impairment demonstrates a disconnect with the existing evidence of their effectiveness,&quot; Teno and colleagues commented. &quot;Many experts have expressed concerns regarding the overuse of feeding tubes.&quot;&lt;/p&gt;
&lt;p&gt;They called for more research into the decision-making processes that produce such variations among hospitals and interventions to reduce unnecessary insertions and those that conflict with patients&apos; preferences.&lt;/p&gt;
&lt;p&gt;Teno and colleagues analyzed data on some 163,000 patients included in the U.S. Nursing Home Minimum Data Set whose records indicated an age greater than 65, advanced cognitive impairment, lack of prior tube feeding, and an acute-care hospitalization from 2000 to 2007.&lt;/p&gt;
&lt;p&gt;They also had data on the size and business structure of the hospitals to which patients were admitted.&lt;/p&gt;
&lt;p&gt;The researchers found the following adjusted odds ratios for hospital characteristics associated with feeding tube insertions: &lt;ul&gt; &lt;li&gt;Business model: 1.33 (95% CI 1.21 to 1.46) for for-profit versus government owned.&lt;/li&gt; &lt;li&gt;Size: 1.48 (95% CI 1.35 to 1.63) for more than 310 beds versus less than 101 beds.&lt;/li&gt; &lt;li&gt;ICU use in failing elderly patients: 2.60 (95% CI 2.20 to 3.06) for highest decile of ICU care in the last six months of life versus the lowest decile.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The adjustments included age, gender, race and ethnicity, medical history, degree of cognitive impairment, advanced care directives, and durable power of attorney.&lt;/p&gt;
&lt;p&gt;The differences were much greater before the adjustments. For example, the raw data showed a rate of 8.0 feeding tube insertions per 100 hospitalizations at large facilities compared with 4.3 per 100 in small hospitals.&lt;/p&gt;
&lt;p&gt;Similarly, hospitals with the most aggressive ICU use in elderly patients had an insertion rate of 10.1 per 100 hospitalizations, while those with the lowest ICU use in such patients had a mean rate of 2.9 per 100.&lt;/p&gt;
&lt;p&gt;Teno and colleagues also found that some other hospital factors  --  such as the ratio of specialists to general medicine physicians and the use of hospice services  --  did not significantly predict feeding tube use.&lt;/p&gt;
&lt;p&gt;On the other hand, indicators of advanced care planning were significantly associated with reduced feeding tube insertions, although perhaps not as much as would be expected.&lt;/p&gt;
&lt;p&gt;Expressed as adjusted odds ratios, the rate reductions were: &lt;ul&gt; &lt;li&gt;Living will: 0.75 (95% CI 0.70 to 0.79)&lt;/li&gt; &lt;li&gt;Durable power of attorney: 0.88 (95% CI 0.84 to 0.91)&lt;/li&gt; &lt;li&gt;DNR orders: 0.65 (95% CI 0.62 to 0.67)&lt;/li&gt; &lt;li&gt;Orders to forgo artificial hydration and nutrition: 0.73 (95% CI 0.67 to 0.80)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;&quot;These results raise more questions than answers,&quot; Teno and colleagues noted in calling for additional research into the reasons for the trends they identified.&lt;/p&gt;
&lt;p&gt;&quot;Future research to examine these reported variations should focus on decision making for feeding tube insertion in hospitalized nursing home residents with dementia. Additionally, the role that hospitals and nursing homes have in advance care planning is critically important,&quot; they wrote, noting that advanced care planning is often neglected in nursing homes.&lt;/p&gt;
&lt;p&gt;Teno and colleagues noted some limitations to the study, notably the reliance on administrative records for most data, as well as the lack of information on physician counseling and patient preferences beyond the orders recorded in the database.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Institute on Aging funded the study.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_469"
                     title="BLOG: Linkfest Today"
                     score="0.01"
                     href="http://www.medpagetoday.com/Blogs/18401?impressionId=1265815583515"
                     
      Test scores have historically been important for prospective medical students.  But sometimes, those who score highest don&apos;t necessarily make the best doctors.  In a &lt;i&gt;New York Times&lt;/i&gt; column, surgeon Pauline Chen discusses a study looking at whether &lt;a href=&quot;http://www.nytimes.com/2010/01/15/health/14chen.html?partner=rss&amp;emc=rss&quot; target=&quot;_blank&quot;&gt;personality traits&lt;/a&gt; would make better predictors.  For instance, according to the study&apos;s author, &amp;quot;If I know someone is not just stress-prone, but stress-prone at the 
95th percentile rather than the 65th. I would have to ask myself if that
 person could handle the stress of medicine.&amp;quot;&lt;br&gt;
&lt;br&gt;
The interview portion of the application process is one way to gauge an applicant&apos;s personality.  But requiring students to take personality tests can standardize this measure, and better predict success.&lt;br&gt;
&lt;br&gt;
***&lt;br&gt;
&lt;br&gt;
More doctors are splitting their time between clinical duties and writing a book.  Surgeon Atul Gawande comes to mind, for instance.  In a guest post, fellow &lt;a href=&quot;http://www.kevinmd.com/blog/2010/02/telling-patient-story-issues-facing-physician-writers.html&quot; target=&quot;_blank&quot;&gt;physician-author&lt;/a&gt; Danielle Ofri talks about some of the issues facing doctors who take up the pen.  &lt;br&gt;
&lt;br&gt;
When talking about how she recounts patient stories, she writes, &amp;quot;I want to give a respectful rendering of my patient&apos;s story, one that
 I hope would honor them and what they&apos;ve endured. Of course this is 
necessarily a subjective decision, but it is the only internal ethic 
that I can live with. My patients have entrusted me with their stories, 
and I need to respect that. If a particular story can edify future 
doctors, or educate the public, there might be value in publishing it.&amp;quot;  &lt;br&gt;
&lt;br&gt;
Great advice, which can also be applied to physician-bloggers as well.&lt;br&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_468"
                     title="DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses"
                     score="0.01"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18399?impressionId=1265815583515"
                     
      &lt;p&gt;Substantial changes are in the offing for the &quot;psychiatrist&apos;s bible,&quot; the Diagnostic and Statistical Manual of Mental Disorders, according to a draft of the forthcoming fifth edition.&lt;/p&gt;
&lt;p&gt;The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, &lt;a href=&quot;http://www.psych.org/dsmv.aspx&quot; mce_href=&quot;http://www.psych.org/dsmv.aspx&quot; target=&quot;_blank&quot;&gt;www.dsm5.org&lt;/a&gt;, to obtain comments from its members, other members of the mental health community, and the public.&lt;/p&gt;
&lt;p&gt;At a telephone press briefing before the draft&apos;s release, members of the APA team leading the DSM revision highlighted several substantial innovations they are proposing: &lt;ul&gt; &lt;li&gt;Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term &quot;mental retardation&quot; with &quot;intellectual disability&quot;&lt;/li&gt; &lt;li&gt;Eliminating &quot;substance abuse&quot; and &quot;substance dependence&quot; as disorders, to be replaced with a single &quot;addiction and related disorders&quot; category&lt;/li&gt; &lt;li&gt;Creating a &quot;behavioral addictions&quot; category that will include addictions to gambling but not to the Internet or sex&lt;/li&gt; &lt;li&gt;Offering a new assessment tool for suicide risk&lt;/li&gt; &lt;li&gt;Including a category of &quot;risk syndromes&quot; for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do&lt;/li&gt; &lt;li&gt;Adding a new disorder in children, &quot;temper dysregulation with dysphoria,&quot; for persistent negative mood with bursts of rage&lt;/li&gt; &lt;li&gt;Revising criteria for some eating disorders, including creation of a separate &quot;binge eating disorder&quot; distinct from bulimia&lt;/li&gt; &lt;li&gt;Using &quot;dimensional assessments&quot; to account for severity of symptoms, especially those that appear in multiple diagnostic categories&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The APA will accept comments through April 20. The work groups managing the revision will consider them and make further changes as needed to the draft, said David Kupfer, MD, of the University of Pittsburgh, chairman of the DSM-V task force.&lt;/p&gt;
&lt;p&gt;The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, &lt;a href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482&quot; mce_href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482&quot; target=&quot;_blank&quot;&gt;a year later than originally planned&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;New Categories for Dyslexia, Autism&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia  --  reflecting disabilities of reading and mathematics, respectively  --  into a new category of learning disabilities.&lt;/p&gt;
&lt;p&gt;Autism, Asperger&apos;s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new &quot;autism and related disorders&quot; category.&lt;/p&gt;
&lt;p&gt;The head of the APA&apos;s work group on substance-related disorders, Charles O&apos;Brien, MD, PhD, of the University of Pennsylvania, told reporters on the press call that substance dependence and abuse had no basis in the research on addictions.&lt;/p&gt;
&lt;p&gt;&quot;We unanimously agreed that . . . there really isn&apos;t evidence for an intermediate stage [short of addiction] that is now known as abuse,&quot; he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.&lt;/p&gt;
&lt;p&gt;He added that the term &quot;dependence&quot; was problematic as a psychiatric diagnosis because some types of physical dependence are &quot;completely normal&quot; for some medications, such as opioid painkillers.&lt;/p&gt;
&lt;p&gt;In fact, under the draft, DSM-V will include &quot;discontinuation syndromes&quot; to allow physicians to properly assess symptoms of withdrawal from psychoactive substances, including caffeine, O&apos;Brien said.&lt;/p&gt;
&lt;p&gt;He also said his work group had considered including sex and Internet addictions as disorders, but decided there was insufficient evidence to allow development of reliable diagnostic criteria for them.&lt;/p&gt;
&lt;p&gt;Consequently, gambling addiction is slated to be the only disorder formally listed in the behavioral addictions category.&lt;/p&gt;
&lt;p&gt;But O&apos;Brien added that, under current plans, sex and Internet addictions would be included in an appendix to DSM-V, intended to encourage additional research that could lead to their inclusion in future editions.&lt;/p&gt;
&lt;p&gt;Carole Lieberman, MD, a Beverly Hills, Calif., psychiatrist who appears frequently on television, regretted the omission of Internet addiction.&lt;/p&gt;
&lt;p&gt;Contacted for comment by &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News, Lieberman said in an e-mail that behavioral addictions are a worthy category. &quot;But why would it not include &apos;Internet addiction,&apos;&quot; she wrote. &quot;Could it be that the psychiatrists involved do not want to acknowledge that their own Internet usage could meet the criteria for addiction?&quot;&lt;/p&gt;
&lt;p&gt;Lieberman added that compulsive shopping was another form of behavioral addiction that deserves recognition.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Dimensional and Risk Assessments&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;APA leaders also emphasized the two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults.&lt;/p&gt;
&lt;p&gt;David Shaffer, MD, of Columbia University, told reporters on the press call that suicide nearly always occurs in the context of some psychiatric disorder, but not always depression.&lt;/p&gt;
&lt;p&gt;The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness.&lt;/p&gt;
&lt;p&gt;In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.&lt;/p&gt;
&lt;p&gt;Shaffer also explained the genesis of the proposed new childhood disorder, temper dysregulation with dysphoria (TDD).&lt;/p&gt;
&lt;p&gt;&quot;About 40% to 60% of the cases [seen by child psychiatrists] will be children who are doing things that other people don&apos;t want them to do,&quot; he said. Many of these are children who are &quot;stubborn and resistant and disobedient and moody.&quot;&lt;/p&gt;
&lt;p&gt;There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness, according to Shaffer.&lt;/p&gt;
&lt;p&gt;Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults.&lt;/p&gt;
&lt;p&gt;He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.&lt;/p&gt;
&lt;p&gt;Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.&lt;/p&gt;
&lt;p&gt;Darrel Regier, MD, MPH, the APA&apos;s research director, said such checklists &quot;don&apos;t always fit the reality that someone with a mental disorder experiences.&quot; Often, a symptom like insomnia isn&apos;t on the checklist for a particular disorder, he said, &quot;but they can still affect patients&apos; lives and affect the treatment planning.&quot;&lt;/p&gt;
&lt;p&gt;Incorporating quantitative dimensional assessments should allow clinicians to develop treatment and response-monitoring plans better tailored to individual patients&apos; needs, Regier said.&lt;/p&gt;
&lt;p&gt;But Lieberman foresaw problems with the dimensional assessments. &quot;I don&apos;t think [they] will add anything but confusion,&quot; she said in an e-mail. &quot;As it is now, people don&apos;t really make use of the subcategories that there are to describe severity of symptoms. Instead, I see this as a tool that insurance companies could well co-opt to try to deny benefits.&quot;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Gender Identity Disorder Stays&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. At this point, the draft retains the designation but with some changes, officials said.&lt;/p&gt;
&lt;p&gt;People who consider themselves &quot;transgendered&quot; have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic  --  that is, they have the wrong genitalia and hormonal balance.&lt;/p&gt;
&lt;p&gt;At the APA&apos;s annual meeting last May, members of the transgender community &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/APA/14270&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/APA/14270&quot; target=&quot;_blank&quot;&gt;made a case&lt;/a&gt; for dropping gender identity disorder from DSM-V, but keeping some kind of &quot;gender variance&quot; diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.&lt;/p&gt;
&lt;p&gt;William Narrow, MD, the APA&apos;s research director for DSM-V, told reporters that the draft does remove the term &quot;disorder&quot; from the condition when applied to children, renaming it as &quot;gender incongruence.&quot;&lt;/p&gt;
&lt;p&gt;For adults, gender identity disorder will remain in DSM-V but with substantially altered diagnostic criteria, Narrow said.&lt;/p&gt;
&lt;p&gt;But APA officials said the organization planned more discussions with members of the transgender community.&lt;/p&gt;
&lt;p&gt;Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.&lt;/p&gt;
&lt;p&gt;Final revisions will be submitted in 2012 for approval by the APA&apos;s two governing bodies, the Assembly and the board of trustees.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
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