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New research sheds light on a rare but disabling psychiatric disorder known as olfactory reference syndrome (ORS), where sufferers are convinced that they emit horrible smells and, as a result, often isolate themselves or even attempt suicide.

“Patients suffer tremendously as a result of this false belief, and they appear to be very impaired in terms of functioning and appear to have high rates of suicidality,” said Dr. Katharine A. Phillips, a professor of psychiatry and human behavior at Rhode Island Hospital/Brown University in Providence. “But ORS is surprisingly minimally studied. It’s not a well-known disorder.”

Phillips, who is to present her research on the syndrome Tuesday at the American Psychiatric Association (APA) annual meeting in New Orleans, spoke at a Tuesday teleconference. The APA is considering whether the syndrome deserves to be defined as its own official disorder in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

“ORS has been described around the world for more than a century,” Phillips explained. “It consists of a preoccupation with the belief that one emits a foul or offensive body odor which is not perceivable by other people.”

Likely cultural standards, especially in earlier times when hygiene was less of a priority, probably also play a role, added Dr. Bryan Page, chairman of anthropology and a professor of psychiatry at the University of Miami Miller School of Medicine.

In the United States, where people are very concerned with cleanliness, for instance, the phobia may be more prevalent, he noted.

The study authors analyzed 20 patients with ORS to determine the general characteristics of the disorder.

Patients in the sample were an average of 33.4 years old and, on average, had been suffering from ORS since they were 15 or 16. Sixty percent were female.

On average, volunteers spent a good three to eight hours a day preoccupied with negative thoughts about their perceived odor. Many also engaged in repetitive activities (perhaps using an entire bar of soap in a day) for hours each day. Eighty-five percent were convinced that their beliefs were completely accurate, even though no one else agreed, Phillips said, and three-quarters felt that others were noticing them because of their “smell.”

“If someone rubs their nose because of an allergy or opens a door, they misinterpret that to think they stink,” Phillips explained.

Three-quarters of the participants were certain they had bad breath. Other sources of perceived odor included sweat (65 percent), armpits (60 percent) and genitals (35 percent).

Ninety-five percent practiced at least one compulsive behavior on a daily basis because of this conviction. Eighty percent smelled themselves continually, 68 percent showered obsessively and 50 percent changed clothing repeatedly. Many used powder or perfume (sometimes even drinking the perfume), deodorant, gum and other products to rid themselves of the scent. One individual actually had their tonsils removed, thinking this would take care of the perceived bad breath.

The syndrome also left many people isolated, with three-quarters saying they avoided social interactions because of the “smell” and 40 percent reporting having been housebound for at least a week. More than two-thirds had contemplated suicide, one-third had attempted suicide and more than half had been hospitalized for psychiatric reasons.

Many also had major depressive disorder and social phobia.

Despite the psychological ramifications of the disorder, 44 percent sought non-psychiatric treatment, such as dentists or dermatologists.

The majority (85 percent) said they could actually smell themselves — an “olfactory hallucination.”

“I would encourage patients to seek psychiatric treatment. As far as we know, non-psychiatric dental and medical treatment doesn’t help,” Phillips said. “Cognitive behavioral therapy has been shown in a small case series to be helpful, and certain medications.”

SOURCES: 2010, teleconference with: Katharine A. Phillips, M.D., professor, psychiatry and human behavior, Rhode Island Hospital/Brown University, Providence; Bryan Page, Ph.D., professor and chairman, anthropology, professor, psychiatry, University of Miami Miller School of Medicine.

People hospitalized with the lung ailment chronic obstructive pulmonary disease (COPD) do better when they receive antibiotics without delay, a new study shows.

COPD patients who were given antibiotics early in their hospital stay were less likely to need mechanical ventilation and less likely to have to be readmitted to the hospital, the researchers said.

The finding could have implications for routine treatment, since “current guidelines for treating COPD exacerbations recommend antibiotics only for patients who have an increase in sputum or purulent [pus-bearing] sputum,” said lead researcher Dr. Michael B. Rothberg, from Baystate Medical Center in Springfield, Mass.

“We looked to see if we could identify a group of patients who would not benefit from antibiotics, but we couldn’t find one,” Rothberg said.

This is not to say that all COPD patients will benefit from antibiotics, Rothberg added. “At present, we only think that about half of COPD exacerbations are caused by infection, so probably only half of patients can benefit from this therapy. The problem is that we don’t know which half,” he said.

The findings were published in the May 26 issue of the Journal of the American Medical Association.

COPD typically involves a combination of bronchitis and emphysema and is often tied to smoking. The disease affects some 12 million people in the United States and is the fourth leading cause of death, according to background information with the study.

According to Rothberg’s group, exacerbations of COPD are responsible for more than 600,000 hospitalizations each year and result in direct costs of more than $20 billion.

For the study, Rothberg’s team looked at the outcomes of almost 85,000 patients hospitalized for exacerbations of COPD in 413 U.S. hospitals from January 2006 to December 2007.

Although 79 percent of patients received antibiotics for at least two days, the timing of treatment was critical to their outcome, the researchers found.

Fewer patients whose antibiotic therapy started in the first two days after hospital admission needed to be put on a mechanical ventilator than patients whose treatment started later (1.07 percent versus 1.8 percent), the team noted.

In addition, fewer of the patients treated early on with antibiotics died (about 1 percent versus close to 1.6 percent for those treated later). Those treated early also had fewer treatment failure (about 9.8 percent versus nearly 12 percent), and a lower rate of hospital readmission for acute exacerbations of COPD (7.9 percent versus about 8.8 percent), the researchers found.

While both groups of patients stayed in the hospital for about the same length of time, the costs for those given antibiotics early was less, the researchers said.

“We need better ways of determining which patients will benefit, but for now all patients with COPD exacerbations bad enough to land them in the hospital should be treated with antibiotics,” Rothberg said.

Dr. Len Horovitz, a pulmonary specialist at Lenox Hill Hospital in New York City, said the results “are not surprising.”

“It’s rather commonplace that a patient with COPD comes in and you are looking for reasons for exacerbation,” he said. “These can be inflammation, infection or some environmental problem — most of the time, of course, you are thinking about infection as the primary reason.”

Horovitz said that oftentimes, respiratory infection in COPD patients can be hard to diagnose from an X-ray. The only way to be sure the patient has pneumonia is by a lab test. But often the results are not available for a day or more.

“The way I was trained was to start antibiotics that were broad-spectrum enough that you could discontinue them should the patient not require it,” he said. “These findings are consistent with the way I approach patients and it did not surprise me that those patients would fare better than patients in whom antibiotics were withheld, pending [lab] cultures.”

SOURCES: Michael B. Rothberg, M.D., M.P.H., Baystate Medical Center, Springfield, Mass.; Len Horovitz, M.D., pulmonary specialist, Lenox Hill Hospital, New York City;

There is a possible increased risk of fractures of the hip, wrist, and spine if you take certain drugs for heartburn, acid reflux, or ulcers, warns the Food and Drug Administration (FDA).

The drugs belong to a class of medications called proton pump inhibitors (PPIs), which work by reducing the amount of acid in the stomach. They are available both as prescription and as over-the-counter (OTC) medications.

The prescription PPIs treat conditions such as gastroesophageal reflux disease (GERD), ulcers in the stomach and small intestine, and inflammation of the esophagus. The PPIs available over-the-counter are used to treat frequent heartburn.

The prescription PPIs are
Nexium
Dexilant
Prilosec
Zegerid
Prevacid
Protonix
Aciphex
Vimovo

The over-the-counter PPIs are
Prilosec OTC (omeprazole)
Zegerid OTC (omeprazole)
Prevacid 24HR (lansoprazole)
Advice for Consumers
Do not stop taking your PPI unless you are told to do so by your health care professional. PPIs are effective in treating a variety of gastrointestinal disorders.
Be aware that an increased risk of fractures of the hip, wrist, and spine have been reported in some studies of people who use PPIs. The greatest increased risk for these fractures was seen in those who receive high doses of these medications or use them for a year or longer.
Read and follow the directions on the “Drug Facts” label when considering the use of an over-the-counter PPI.
Be aware that the over-the-counter PPIs should only be used as directed for 14 days for the treatment of frequent heartburn. If your heartburn continues, talk to your health care professional. No more than three 14-day treatment courses should be used in one year.
Talk to your health care professional about any concerns you may have about using PPIs.
Report any side effects from the use of PPIs to FDA’s MedWatch Adverse Event Reporting Program either online, by regular mail, by fax, or by phone.
Online
Regular Mail: Use postage-paid, pre-addressed FDA form 3500
Fax: 1-800-FDA-0178
Phone: 1-800-332-1088
FDA Actions

FDA has reviewed seven published studies, six of which reported an increased risk of fractures of the hip, wrist, and spine with the use of PPIs. Based on the available data, it is not clear at this time if the use of PPIs is the cause of the increased risk of fractures seen in some studies. FDA is working with the manufacturers of PPIs to further study this possible risk.

Most of the studies evaluated individuals 50 years of age or older, and the increased risk of fracture was seen mainly in this age group.

As a precaution, FDA is revising the labels for both the prescription and the over-the-counter PPIs to include new safety information about the possible increased risk of fractures of the hip, wrist, and spine with the use of these medications.

This article appears on FDA’s Consumer Updates page, which features the latest on all FDA-regulated products.

Effective but expensive biologic drugs are less likely to be used by American rheumatoid arthritis patients who have inadequate health insurance or are struggling with medical co-payments, a new study reveals.

Biologics, which alter immune system function, are sometimes used to treat rheumatoid arthritis when more conventional treatments don’t work.

“Our study showed that out-of-pocket cost is a concern in the decision to initiate these drugs,” lead author Pinar Karaca-Mandic, an assistant professor in the School of Public Health at the University of Minnesota, said in a news release. “If higher cost-sharing forces people away from preferred, effective therapy, they could end up with higher complication and medical costs.”

Karaca-Mandic and her research team released their findings online May 24 in advance of publication in an upcoming print issue of the journal Health Services Research.

The cautionary note stems from an analysis of health insurance data gleaned from 35 large, private U.S. employers from 2000 to 2005.

From a pool of more than 8,500 newly diagnosed rheumatoid arthritis patients, the authors found that 2,066 of them had used one of the three most commonly prescribed biotech drugs: etanercept (Enbrel), adalimumab (Humira) or infliximab (Remicade).

However, the team found that the likelihood of taking any of these drugs was lower among patients who had to pay more for them. What’s more, unmanageable costs also raised the risk that those who started a biotech regimen would end up abandoning the treatment.

Rheumatoid arthritis patients from families already burdened with high health costs overall were less than 50 percent as likely to begin a biotech regimen in the first place, the authors found, although those who did so anyway were not more likely to stop once they started.

“Families have a separate budget for health care, and may not be flexible around expanding it,” noted Karaca-Mandic. “If other members are getting sick, they may want to draw resources away from the rheumatoid arthritis patient.”

Infusion pumps used in hospitals and homes to deliver medication and nutrients to patients have been a source of persistent safety problems that have now prompted the U.S. Food and Drug Administration to address these issues, health officials said Friday.

Over the past five years, the FDA has received more than 56,000 reports of problems with these pumps, including more than 500 deaths.

“These pumps often provide critical fluids to high-risk patients, so failures have significant implications,” Dr. Jeffrey Shuren, director of FDA’s Center for Devices and Radiological Health, said in a news release. “It is time for a more comprehensive approach than we’ve taken to date.”

According to the FDA, from 2005 to 2009, there were 87 infusion pump recalls to deal with safety problems.

Common infusion pump problems include:
Software glitches such as failures of safety alarms.
Confusing instructions leading to dosing errors.
Mechanical or electrical failures, such as battery failures, sparks or pump fires.

These problems have been found in pumps from many manufacturers and are most likely caused by defects in the design and engineering of these products, according to the agency.

To start correcting these problems, the FDA has sent a letter to pump manufacturers advising them that additional risk assessments may need to be conducted to support clearance of new or modified pumps.

In addition, the agency has published a draft guidance recommending that infusion pump manufacturers start providing additional design and engineering data to FDA during premarket review of the devices.

The letter also invites manufacturers to submit their infusion pump software codes to the agency for analysis of potential software problems.

The FDA is also asking doctors to consider the following steps to make infusion pumps safer to use:
Be prepared to deal with pump failures.
Label pumps and tubing to avoid errors.
Check pump settings to prevent under-dosing or overdosing.
Report problems to the FDA.

SOURCE: U.S. Food and Drug Administration, news release.

Children with autism whose social and communications skills regress around age 3 tend to have more severe autism than children who show signs of the neurodevelopmental disorder at younger ages, new research finds.

Autism spectrum disorders are marked by delays or disruptions in social, language and communications skills, and restricted or repetitive behaviors or interests. Increasingly, doctors are coming to understand that there are several subtypes of the disorder, explained senior study author Dr. Paul Law, director of the Interactive Autism Network at Kennedy Krieger Institute in Baltimore.

In the study, researchers used data from 2,720 parents of children aged 3 to 17 years who had been diagnosed with an autism spectrum disorder. Children were placed in one of three groups, depending on how and when their autism symptoms started:
Regressive, in which children seemed to be developing generally normally or close to normally, but then experienced a sharp decline in skills before age 3. About 44 percent of the children were in this group.
Plateau, or the 17 percent of children who were not delayed or only mildly delayed until about age 2, at which point they gradually or abruptly stop developing.
No loss/no plateau, sometimes called early onset autism, in which subtle signs of autism show up at relatively younger ages, but children don’t regress or plateau. About 39 percent of the children fell into this category.

The researchers found some notable differences between the groups. In children who regressed or plateaued, parents said they first became concerned about their child’s development at about 17 months, compared to about 15 months for children who did not plateau or regress.

Children who regressed said their first word at about 14 months, compared to 20 months for children who plateaued and 21 months for those with no loss/no plateau autism.

Another difference: Children who regressed took longer to potty train — about 52 months, compared to about 48 months for other children with autism.

Over time, children who regressed tended to end up with more severe autism. They were at the greatest risk for not attaining conversational speech, and were more likely than the other groups to need educational support, such as a classroom aide. The more marked the regression, the more severe the autism later on, according to the study.

Autism with regression is much debated among researchers, with some estimates putting the prevalence at one-third to one-half of children with the disorder, with others saying as few as 15 percent of children experience regression.

Study author Luther Kalb, a researcher at the Center for Autism and Related Disorders at the Kennedy Krieger Institute, said some of the discrepancy may be definitions of regression — some consider autism regression to be only children who had no symptoms of autism prior to the decline in previously acquired skills, while others allow for some delays prior to losing skills.

In the study, about 35 percent of parents had concerns about their child’s development before their child began losing skills.

The study was published online April 20 in the Journal of Autism and Developmental Disorders.

“There are still discussions within the science community about how exactly to define regression,” added Andy Shih, vice president of scientific affairs for Autism Speaks. “This study certainly adds to the body of evidence that suggests there is a differentiation between different types of autism development progression and outcomes for the individual.”

Parents whose child has experienced regression should take heart, Law said, and remember that the statistics show trends, not how an individual child will do. “A lot of children with regression did well,” Law said. “There is a lot of individual variation. This is by no means a very dire sentence.”

Among the first signs of autism typically noticed by parents are lack of eye contact or social smiles, speech delays, restricted interests, hand waving or flapping, or generally not engaging with others in the ways other children do, Kalb said.

If parents notice any losses in a child’s vocabulary or social skills, or the child seems to have stopped progressing, they should have the child evaluated by a pediatrician right away, all of the experts stressed.

“What we do know is that the earlier we identify children who may be at risk for autism and provide early intervention, the better the prognosis and the more likely you are to have better outcomes,” Shih said.

SOURCES: Luther Kalb, MPH, researcher, Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore; Paul Law, M.D., director, Interactive Autism Network, Kennedy Krieger Institute, Baltimore; Andy Shih, Ph.D., vice president, scientific affairs, Autism Speaks, New York City;

Patients with type 2 diabetes who can’t control their blood glucose levels with the drug metformin alone do better after adding injections of the drug liraglutide compared to oral doses of another drug called sitagliptin, researchers report.

In the study, Dr. Richard E. Pratley, of the University of Vermont College of Medicine in Burlington, and his colleagues randomly assigned patients whose blood glucose wasn’t sufficiently controlled by metformin (Glucophage) to receive 26 weeks of treatment with liraglutide (Victoza) by injection or sitagliptin (Januvia) by mouth.

The researchers found that the patients did better on liraglutide, although between 21 percent and 27 percent of patients reported nausea, compared to 5 percent of those on sitagliptin, according to the report published in the April 24 issue of The Lancet.

Liraglutide “was well-tolerated with minimum risk of hypoglycemia. These findings support the use of liraglutide as an effective agent to add to metformin,” they wrote in a news release from the journal.

In a commentary accompanying the study, Dr. Andre J. Scheen and Dr. Regis P. Radermecker of the University of Liege in Belgium noted that patients may think it’s easier to take one sitagliptin pill a day compared to daily injections of liraglutide. And liraglutide, they added, is more expensive, but it has improved benefits in terms of blood glucose control and weight reduction.

New research suggests that cocaine overdose deaths in New York City go up with the temperature: They’re more likely when the average weekly temperature goes past 75 degrees Fahrenheit.

The findings, published online March 3 in the journal Addiction, are based on death statistics in the city from 1990 through 2006.

The increase in accidental overdose deaths during warmer temperatures appears to be because cocaine raises body temperature and makes it harder for the cardiovascular system to cool the body, according to background information from the journal’s publisher. When using cocaine, people also tend to be less apt to comprehend that they’re hot and need to do something to cool off.

The research clarifies earlier findings that had linked cocaine overdose deaths to much higher temperatures — those over about 88 degrees Fahrenheit.

The study estimated that the number of cocaine overdose deaths in New York City would rise by at least two a week when the average temperature is higher than 75 degrees, compared with an average of 75 degrees or lower.

What to do? Air conditioning and special health alerts could help in urban areas where cocaine use is high, the study suggested.

SOURCE: Wiley-Blackwell

Sports are the most common cause of shoulder dislocation, and young males have the highest risk of suffering this type of injury, a new study shows.

Researchers studied 8,940 shoulder dislocations treated at 100 hospital emergency rooms across the United States from 2002 to 2006 and found that the overall incidence rate was 23.9 shoulder dislocations per 100,000 person years (the number of years times the number of members of a population affected by a certain condition).

The study author also found that: 71.8 percent of shoulder dislocations occurred in men; 46.8 percent were in patients aged 15 to 29; 48.3 percent occurred during sports or recreation; and 37 percent of all sports-related injuries occurred while playing football or basketball.

The majority of dislocations were caused by a fall. Of those falls, 47.7 percent occurred at home and 33.6 percent occurred at sports or recreation sites. Among women, those aged 80 to 90 had higher shoulder dislocation rates, mostly because of falls at home.

“We were not too surprised to find the high number of young males dislocating their shoulders during athletic activity. However, the rate of shoulder dislocations among elderly women was higher than we had previously assumed,” study co-author Dr. Brett Owens, an orthopedic surgeon at Keller Army Hospital in West Point, N.Y., and an associate professor at the Uniformed Services University of the Health Sciences, said in a news release.

The study appears in the March issue of The Journal of Bone and Joint Surgery.

Symptoms of shoulder dislocation include pain, swelling, numbness, weakness and bruising. A shoulder dislocation can tear ligaments or tendons in the shoulder and may cause nerve damage.

SOURCE: The Journal of Bone and Joint Surgery