Heidi Splete

WASHINGTON — Hypotensive emergency department patients with sepsis had 2.7 times higher mortality than patients without sepsis, with the exception of patients in cardiogenic shock, Michael Filbin, M.D., reported in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Dr. Filbin and his colleagues at Massachusetts General Hospital in Boston conducted a prospective study of 19,474 patients older than 18 years. Of these, 321 patients presented with hypotension or developed hypotension during their time in the emergency department. Hypotension was defined as at least two consecutive systolic blood pressures at or below 90 mm Hg.

Mortality among the patients with hypotension was 12% (38 of the 321 patients), and hypotension was significantly correlated with overall mortality. Overall mortality was 1.1% in the general emergency department population during the study period.

After adjustment for age, duration of hypotension, and frequency of systolic blood pressure assessment, mortality was highest among cardiogenic patients (23%) and septic patients (19%). However, when cardiogenic patients were excluded, septic patients had the highest mortality.

Although such a finding appears intuitive, few systematic studies have analyzed a consecutive series of patients with low blood pressure, the researchers noted.

WASHINGTON — Hypotensive emergency department patients with sepsis had 2.7 times higher mortality than patients without sepsis, with the exception of patients in cardiogenic shock, Michael Filbin, M.D., reported in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Dr. Filbin and his colleagues at Massachusetts General Hospital in Boston conducted a prospective study of 19,474 patients older than 18 years. Of these, 321 patients presented with hypotension or developed hypotension during their time in the emergency department. Hypotension was defined as at least two consecutive systolic blood pressures at or below 90 mm Hg.

Mortality among the patients with hypotension was 12% (38 of the 321 patients), and hypotension was significantly correlated with overall mortality. Overall mortality was 1.1% in the general emergency department population during the study period.

After adjustment for age, duration of hypotension, and frequency of systolic blood pressure assessment, mortality was highest among cardiogenic patients (23%) and septic patients (19%). However, when cardiogenic patients were excluded, septic patients had the highest mortality.

Although such a finding appears intuitive, few systematic studies have analyzed a consecutive series of patients with low blood pressure, the researchers noted.

WASHINGTON — Hypotensive emergency department patients with sepsis had 2.7 times higher mortality than patients without sepsis, with the exception of patients in cardiogenic shock, Michael Filbin, M.D., reported in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Dr. Filbin and his colleagues at Massachusetts General Hospital in Boston conducted a prospective study of 19,474 patients older than 18 years. Of these, 321 patients presented with hypotension or developed hypotension during their time in the emergency department. Hypotension was defined as at least two consecutive systolic blood pressures at or below 90 mm Hg.

Mortality among the patients with hypotension was 12% (38 of the 321 patients), and hypotension was significantly correlated with overall mortality. Overall mortality was 1.1% in the general emergency department population during the study period.

After adjustment for age, duration of hypotension, and frequency of systolic blood pressure assessment, mortality was highest among cardiogenic patients (23%) and septic patients (19%). However, when cardiogenic patients were excluded, septic patients had the highest mortality.

Although such a finding appears intuitive, few systematic studies have analyzed a consecutive series of patients with low blood pressure, the researchers noted.

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study.

The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties.

Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference.

This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University.

The intervention itself included specific courses on the importance of preventive medicine for the students themselves and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted.

During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took approximately 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs.

However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine.

Data from the 16-school natural history study currently under review also show that the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, Dr. Frank said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their personal health habits, she noted.

She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her personal health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk about the importance of diet and exercise, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Family Med. 2000:9:287–90).

Overall, patients who viewed the physician-disclosure video rated the physician as significantly more believable and motivating compared with physician ratings among viewers of the nondisclosure video.

But many doctors—even those with healthy habits—still balk at talking to patients about such subjects as diet, smoking, and exercise.

“A fair amount of lifestyle counseling makes doctors nervous,” Dr. Frank said. “I think part of the issue is that many doctors don't want the additional responsibility of being role models, and I think that's naive, because we've got it even if we don't want it.”

For instance, an overweight doctor who lectures a patient on the importance of maintaining a healthy weight is likely not as believable as a doctor with a healthy weight, she said.

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.

“If schools are interested in doing this, they should contact me and talk [about] how to evaluate the results,” she said. “I think that this is an extremely promising new modality, but we need to learn what students go on to do. We can't test this on mice,” she said.

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study.

The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties.

Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference.

This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University.

The intervention itself included specific courses on the importance of preventive medicine for the students themselves and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted.

During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took approximately 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs.

However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine.

Data from the 16-school natural history study currently under review also show that the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, Dr. Frank said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their personal health habits, she noted.

She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her personal health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk about the importance of diet and exercise, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Family Med. 2000:9:287–90).

Overall, patients who viewed the physician-disclosure video rated the physician as significantly more believable and motivating compared with physician ratings among viewers of the nondisclosure video.

But many doctors—even those with healthy habits—still balk at talking to patients about such subjects as diet, smoking, and exercise.

“A fair amount of lifestyle counseling makes doctors nervous,” Dr. Frank said. “I think part of the issue is that many doctors don't want the additional responsibility of being role models, and I think that's naive, because we've got it even if we don't want it.”

For instance, an overweight doctor who lectures a patient on the importance of maintaining a healthy weight is likely not as believable as a doctor with a healthy weight, she said.

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.

“If schools are interested in doing this, they should contact me and talk [about] how to evaluate the results,” she said. “I think that this is an extremely promising new modality, but we need to learn what students go on to do. We can't test this on mice,” she said.

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study.

The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties.

Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference.

This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University.

The intervention itself included specific courses on the importance of preventive medicine for the students themselves and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted.

During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took approximately 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs.

However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine.

Data from the 16-school natural history study currently under review also show that the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, Dr. Frank said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their personal health habits, she noted.

She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her personal health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk about the importance of diet and exercise, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Family Med. 2000:9:287–90).

Overall, patients who viewed the physician-disclosure video rated the physician as significantly more believable and motivating compared with physician ratings among viewers of the nondisclosure video.

But many doctors—even those with healthy habits—still balk at talking to patients about such subjects as diet, smoking, and exercise.

“A fair amount of lifestyle counseling makes doctors nervous,” Dr. Frank said. “I think part of the issue is that many doctors don't want the additional responsibility of being role models, and I think that's naive, because we've got it even if we don't want it.”

For instance, an overweight doctor who lectures a patient on the importance of maintaining a healthy weight is likely not as believable as a doctor with a healthy weight, she said.

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.

“If schools are interested in doing this, they should contact me and talk [about] how to evaluate the results,” she said. “I think that this is an extremely promising new modality, but we need to learn what students go on to do. We can't test this on mice,” she said.

Girls' Body Images Can Be Bolstered

Adolescent girls who reported peer and parental attitudes that encouraged healthy behavior and exercise, rather than weight loss, were significantly more likely to report high levels of body satisfaction, said Amy M. Kelly, M.D., and her colleagues at the University of Minnesota, Minneapolis.

Overall, 26.7% of 2,357 middle and high school students surveyed in 1998–1999 reported high body satisfaction (J. Adolesc. Health 2005;37:391–6).

The study population included 46% whites, 21% Asian Americans, 20% African Americans, and 5% Hispanics. Body satisfaction was significantly higher among African American girls (40%) and underweight girls (39%) after controlling for ethnicity, socioeconomic status, and age. Girls with high body satisfaction were more likely to report having mothers who exercised for fitness and who encouraged them to be active and eat healthfully.

In addition, girls who reported high body satisfaction were more likely to report that they cared about their health, being fit, and exercising.

Group CBT as Effective as Sertraline

Children and adolescents aged 9–17 years with obsessive-compulsive disorder demonstrated equally significant symptom reductions after being randomized to 12 weeks of sertraline (Zoloft) or 12 weeks of group cognitive-behavioral therapy, said Fernando Ramos Asbahr, M.D., of the University of São Paulo (Brazil), and his colleagues (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1128–36).

Although 10 of 18 patients (56%) who received sertraline required reintroduction of the drug during the 9-month follow-up, only 1 of 19 (5%) of the group therapy patients relapsed during follow-up.

The weekly 90-minute group therapy sessions, directed by cognitive-behavioral therapists, included education about OCD, cognitive training, and family therapy.

Smoking Stunts Girls' Growth

Persistent cigarette smoking retards physical growth in early adolescence, based on data from a 3-year follow-up study of 496 girls aged 11–15 years, said Eric Stice, Ph.D., and Erin E. Martinez, of the University of Texas at Austin.

Persistent smoking–defined as daily smoking between baseline and at 1-year follow-up or between 1-year and 2-year follow-up–was associated with a 34% reduction in height growth, 53% reduction in weight gain, and 71% reduction in BMI during a 1-year interval compared with nonsmokers (J. Adolesc. Health 2005;37:363–70). Smoking initiation in adolescence was associated with a 36% reduction in weight gain and a 68% reduction in BMI but not with significant changes in height growth, compared with nonsmokers.

Termination of smoking during adolescence was associated with barely significant increases in weight and BMI, but not with significant changes in height.

Academic Problems Beget Bullying

Elementary school students who suffer from psychosocial distress are more likely to be involved in bullying, and those with academic problems are more likely to be victims or bully-victims, according to a cross-sectional study of 3,530 children, wrote Gwen M. Glew, M.D., of the University of Washington, Seattle, and her associates.

About 22% of third-, fourth-, and fifth-grade students reported involvement in bullying as either the bully, the victim, or both (bully-victims) in a cross-sectional study of data from a school-based survey. Overall, lower levels of school achievement, feeling unsafe at school, feelings of not belonging at school, and feeling sad were positively associated with being a victim rather than a bystander (Arch. Pediatr. Adolesc. Med. 2005;159:1026–31).

Students who reported feeling unsafe or feeling sad most days were 2.5 times and 1.5 times, respectively, more likely to be a bully than a bystander. In addition, feeling unsafe, feelings of not belonging at school, and lower school achievement were associated with increased odds of being a bully-victim rather than a bystander.

Drug Reduces Disruptive Behavior

Daily risperidone was significantly more effective than placebo at reducing disruptive behaviors in children aged 5–17 years with autism spectrum disorders, said Pieter W. Troost, M.D., of the University of Groningen (the Netherlands), and his associates.

After 24 weeks of treatment in an open-label study, 18 of 26 children (69%) who received risperidone (Risperdal) were rated “much improved” or “very much improved” on the Clinical Global Impressions Scale of Symptom Change. During the discontinuation phase that followed the study phase, 8 of 12 children (67%) randomized to a placebo suffered relapses, compared with 3 of 12 (25%) who continued to take risperidone. The mean dose was 1.51 mg/kg at 8 weeks of treatment and increased to a mean of 1.81 mg/kg at 24 weeks to ensure treatment effects.

Girls' Body Images Can Be Bolstered

Adolescent girls who reported peer and parental attitudes that encouraged healthy behavior and exercise, rather than weight loss, were significantly more likely to report high levels of body satisfaction, said Amy M. Kelly, M.D., and her colleagues at the University of Minnesota, Minneapolis.

Overall, 26.7% of 2,357 middle and high school students surveyed in 1998–1999 reported high body satisfaction (J. Adolesc. Health 2005;37:391–6).

The study population included 46% whites, 21% Asian Americans, 20% African Americans, and 5% Hispanics. Body satisfaction was significantly higher among African American girls (40%) and underweight girls (39%) after controlling for ethnicity, socioeconomic status, and age. Girls with high body satisfaction were more likely to report having mothers who exercised for fitness and who encouraged them to be active and eat healthfully.

In addition, girls who reported high body satisfaction were more likely to report that they cared about their health, being fit, and exercising.

Group CBT as Effective as Sertraline

Children and adolescents aged 9–17 years with obsessive-compulsive disorder demonstrated equally significant symptom reductions after being randomized to 12 weeks of sertraline (Zoloft) or 12 weeks of group cognitive-behavioral therapy, said Fernando Ramos Asbahr, M.D., of the University of São Paulo (Brazil), and his colleagues (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1128–36).

Although 10 of 18 patients (56%) who received sertraline required reintroduction of the drug during the 9-month follow-up, only 1 of 19 (5%) of the group therapy patients relapsed during follow-up.

The weekly 90-minute group therapy sessions, directed by cognitive-behavioral therapists, included education about OCD, cognitive training, and family therapy.

Smoking Stunts Girls' Growth

Persistent cigarette smoking retards physical growth in early adolescence, based on data from a 3-year follow-up study of 496 girls aged 11–15 years, said Eric Stice, Ph.D., and Erin E. Martinez, of the University of Texas at Austin.

Persistent smoking–defined as daily smoking between baseline and at 1-year follow-up or between 1-year and 2-year follow-up–was associated with a 34% reduction in height growth, 53% reduction in weight gain, and 71% reduction in BMI during a 1-year interval compared with nonsmokers (J. Adolesc. Health 2005;37:363–70). Smoking initiation in adolescence was associated with a 36% reduction in weight gain and a 68% reduction in BMI but not with significant changes in height growth, compared with nonsmokers.

Termination of smoking during adolescence was associated with barely significant increases in weight and BMI, but not with significant changes in height.

Academic Problems Beget Bullying

Elementary school students who suffer from psychosocial distress are more likely to be involved in bullying, and those with academic problems are more likely to be victims or bully-victims, according to a cross-sectional study of 3,530 children, wrote Gwen M. Glew, M.D., of the University of Washington, Seattle, and her associates.

About 22% of third-, fourth-, and fifth-grade students reported involvement in bullying as either the bully, the victim, or both (bully-victims) in a cross-sectional study of data from a school-based survey. Overall, lower levels of school achievement, feeling unsafe at school, feelings of not belonging at school, and feeling sad were positively associated with being a victim rather than a bystander (Arch. Pediatr. Adolesc. Med. 2005;159:1026–31).

Students who reported feeling unsafe or feeling sad most days were 2.5 times and 1.5 times, respectively, more likely to be a bully than a bystander. In addition, feeling unsafe, feelings of not belonging at school, and lower school achievement were associated with increased odds of being a bully-victim rather than a bystander.

Drug Reduces Disruptive Behavior

Daily risperidone was significantly more effective than placebo at reducing disruptive behaviors in children aged 5–17 years with autism spectrum disorders, said Pieter W. Troost, M.D., of the University of Groningen (the Netherlands), and his associates.

After 24 weeks of treatment in an open-label study, 18 of 26 children (69%) who received risperidone (Risperdal) were rated “much improved” or “very much improved” on the Clinical Global Impressions Scale of Symptom Change. During the discontinuation phase that followed the study phase, 8 of 12 children (67%) randomized to a placebo suffered relapses, compared with 3 of 12 (25%) who continued to take risperidone. The mean dose was 1.51 mg/kg at 8 weeks of treatment and increased to a mean of 1.81 mg/kg at 24 weeks to ensure treatment effects.

Girls' Body Images Can Be Bolstered

Adolescent girls who reported peer and parental attitudes that encouraged healthy behavior and exercise, rather than weight loss, were significantly more likely to report high levels of body satisfaction, said Amy M. Kelly, M.D., and her colleagues at the University of Minnesota, Minneapolis.

Overall, 26.7% of 2,357 middle and high school students surveyed in 1998–1999 reported high body satisfaction (J. Adolesc. Health 2005;37:391–6).

The study population included 46% whites, 21% Asian Americans, 20% African Americans, and 5% Hispanics. Body satisfaction was significantly higher among African American girls (40%) and underweight girls (39%) after controlling for ethnicity, socioeconomic status, and age. Girls with high body satisfaction were more likely to report having mothers who exercised for fitness and who encouraged them to be active and eat healthfully.

In addition, girls who reported high body satisfaction were more likely to report that they cared about their health, being fit, and exercising.

Group CBT as Effective as Sertraline

Children and adolescents aged 9–17 years with obsessive-compulsive disorder demonstrated equally significant symptom reductions after being randomized to 12 weeks of sertraline (Zoloft) or 12 weeks of group cognitive-behavioral therapy, said Fernando Ramos Asbahr, M.D., of the University of São Paulo (Brazil), and his colleagues (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1128–36).

Although 10 of 18 patients (56%) who received sertraline required reintroduction of the drug during the 9-month follow-up, only 1 of 19 (5%) of the group therapy patients relapsed during follow-up.

The weekly 90-minute group therapy sessions, directed by cognitive-behavioral therapists, included education about OCD, cognitive training, and family therapy.

Smoking Stunts Girls' Growth

Persistent cigarette smoking retards physical growth in early adolescence, based on data from a 3-year follow-up study of 496 girls aged 11–15 years, said Eric Stice, Ph.D., and Erin E. Martinez, of the University of Texas at Austin.

Persistent smoking–defined as daily smoking between baseline and at 1-year follow-up or between 1-year and 2-year follow-up–was associated with a 34% reduction in height growth, 53% reduction in weight gain, and 71% reduction in BMI during a 1-year interval compared with nonsmokers (J. Adolesc. Health 2005;37:363–70). Smoking initiation in adolescence was associated with a 36% reduction in weight gain and a 68% reduction in BMI but not with significant changes in height growth, compared with nonsmokers.

Termination of smoking during adolescence was associated with barely significant increases in weight and BMI, but not with significant changes in height.

Academic Problems Beget Bullying

Elementary school students who suffer from psychosocial distress are more likely to be involved in bullying, and those with academic problems are more likely to be victims or bully-victims, according to a cross-sectional study of 3,530 children, wrote Gwen M. Glew, M.D., of the University of Washington, Seattle, and her associates.

About 22% of third-, fourth-, and fifth-grade students reported involvement in bullying as either the bully, the victim, or both (bully-victims) in a cross-sectional study of data from a school-based survey. Overall, lower levels of school achievement, feeling unsafe at school, feelings of not belonging at school, and feeling sad were positively associated with being a victim rather than a bystander (Arch. Pediatr. Adolesc. Med. 2005;159:1026–31).

Students who reported feeling unsafe or feeling sad most days were 2.5 times and 1.5 times, respectively, more likely to be a bully than a bystander. In addition, feeling unsafe, feelings of not belonging at school, and lower school achievement were associated with increased odds of being a bully-victim rather than a bystander.

Drug Reduces Disruptive Behavior

Daily risperidone was significantly more effective than placebo at reducing disruptive behaviors in children aged 5–17 years with autism spectrum disorders, said Pieter W. Troost, M.D., of the University of Groningen (the Netherlands), and his associates.

After 24 weeks of treatment in an open-label study, 18 of 26 children (69%) who received risperidone (Risperdal) were rated “much improved” or “very much improved” on the Clinical Global Impressions Scale of Symptom Change. During the discontinuation phase that followed the study phase, 8 of 12 children (67%) randomized to a placebo suffered relapses, compared with 3 of 12 (25%) who continued to take risperidone. The mean dose was 1.51 mg/kg at 8 weeks of treatment and increased to a mean of 1.81 mg/kg at 24 weeks to ensure treatment effects.

ST. LOUIS — There were no maternal or fetal deaths in a study of 13 pregnant women with hypertrophic cardiomyopathy.

Women with this condition can have successful pregnancies with minimal risk to themselves and their babies, and should not be discouraged from becoming pregnant, Neeru Kaushik, M.D., reported in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

“Our understanding of hypertrophic cardiomyopathy has changed,” Dr. Kaushik said in an interview. “Most women with HCM don't need invasive monitoring during delivery.”

Dr. Kaushik and her colleagues at Magee-Women's Hospital in Pittsburgh reviewed 13 women aged 17–36 years with 16 pregnancies who were seen in the department of maternal-fetal cardiology from 1989 to 2005.

The women had maternal echocardiograms at 20 and 30 weeks' gestation and at 6 weeks post partum and fetal echocardiograms between 18 and 30 weeks' gestation. Maternal echocardiograms showed a median septal wall thickness of 2.3 cm, and the median predicted Doppler gradient in the left ventricular outflow tract was 37 mm Hg.

All the women delivered in a perinatal special care unit. One woman had a cesarean delivery, and the rest had assisted vaginal deliveries with a shortened second stage of labor. The maternal heart rates remained in the range of 70–80 beats per minute, controlled with atenolol or verapamil in most cases.

Central venous pressure used was not necessary, the investigators said.

ST. LOUIS — There were no maternal or fetal deaths in a study of 13 pregnant women with hypertrophic cardiomyopathy.

Women with this condition can have successful pregnancies with minimal risk to themselves and their babies, and should not be discouraged from becoming pregnant, Neeru Kaushik, M.D., reported in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

“Our understanding of hypertrophic cardiomyopathy has changed,” Dr. Kaushik said in an interview. “Most women with HCM don't need invasive monitoring during delivery.”

Dr. Kaushik and her colleagues at Magee-Women's Hospital in Pittsburgh reviewed 13 women aged 17–36 years with 16 pregnancies who were seen in the department of maternal-fetal cardiology from 1989 to 2005.

The women had maternal echocardiograms at 20 and 30 weeks' gestation and at 6 weeks post partum and fetal echocardiograms between 18 and 30 weeks' gestation. Maternal echocardiograms showed a median septal wall thickness of 2.3 cm, and the median predicted Doppler gradient in the left ventricular outflow tract was 37 mm Hg.

All the women delivered in a perinatal special care unit. One woman had a cesarean delivery, and the rest had assisted vaginal deliveries with a shortened second stage of labor. The maternal heart rates remained in the range of 70–80 beats per minute, controlled with atenolol or verapamil in most cases.

Central venous pressure used was not necessary, the investigators said.

ST. LOUIS — There were no maternal or fetal deaths in a study of 13 pregnant women with hypertrophic cardiomyopathy.

Women with this condition can have successful pregnancies with minimal risk to themselves and their babies, and should not be discouraged from becoming pregnant, Neeru Kaushik, M.D., reported in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

“Our understanding of hypertrophic cardiomyopathy has changed,” Dr. Kaushik said in an interview. “Most women with HCM don't need invasive monitoring during delivery.”

Dr. Kaushik and her colleagues at Magee-Women's Hospital in Pittsburgh reviewed 13 women aged 17–36 years with 16 pregnancies who were seen in the department of maternal-fetal cardiology from 1989 to 2005.

The women had maternal echocardiograms at 20 and 30 weeks' gestation and at 6 weeks post partum and fetal echocardiograms between 18 and 30 weeks' gestation. Maternal echocardiograms showed a median septal wall thickness of 2.3 cm, and the median predicted Doppler gradient in the left ventricular outflow tract was 37 mm Hg.

All the women delivered in a perinatal special care unit. One woman had a cesarean delivery, and the rest had assisted vaginal deliveries with a shortened second stage of labor. The maternal heart rates remained in the range of 70–80 beats per minute, controlled with atenolol or verapamil in most cases.

Central venous pressure used was not necessary, the investigators said.

WASHINGTON — Recent orthopedic research challenges many standards of emergency orthopedics drawn from the archetypal textbook that every medical school uses, Gregory W. Hendey, M.D., said at the annual meeting of the American College of Emergency Physicians.

Dr. Hendey of the University of California, San Francisco, debunked several myths:

▸ Preoperative skin traction reduces the pain associated with hip fracture.

The reality: A Cochrane review from 2003 including eight randomized trials and 1,349 patients showed no benefit from either skin or skeletal traction, compared with no traction for preoperative hip-fracture pain relief.

No significant difference in pain was reported after the first night following the hip fracture in a study of 311 patients randomized to skin traction vs. no traction (Int. Orthop. 2002;26:361–4). To relieve the considerable pain that some of these patients experience, consider a femoral nerve block, advised Dr. Hendey, research director of the UCSF Fresno emergency medicine residency program. In a relatively small study, patients who received a nerve block used significantly fewer analgesics than did those who didn't receive the block.

▸ A scapula fracture is associated with life-threatening injuries and requires an extensive workup.

The reality: Previous studies have shown that a high percentage of patients with a scapula fracture have other problems, but these results may be caused by the use of trauma registries for patient selection.

In a study of 11,500 patients from two trauma centers, 92 patients with scapula fracture were compared with 81 matched controls. Although scapula fracture was significantly associated with thoracic injury (49% vs. 6%), there was no significant difference in mortality or neurovascular morbidity between the two groups (Ann. Emerg. Med. 1995;26:439–42).

▸ A boxer's fracture must be reduced and immobilized with an ulnar gutter splint.

The reality: Strength and alignment are similar in splinted and nonsplinted patients, according to several studies.

In a prospective study of 29 patients with subcapital fifth metacarpal fractures randomized to either reduction and splint or functional treatment, all the fractures healed well. The functional group recovered faster, however, with better strength and range of motion than the reduction and splint group (Scand. J. Plast. Reconstr. Surg. Hand. Surg. 1999;33:315–7).

▸ Nursemaid's elbow is best reduced with rapid supination and elbow flexion.

The reality: Most physicians learned that the way to reduce nursemaid's elbow is rapid supination and flexion. That method works, but there is a kinder, gentler way, Dr. Hendey said.

In supination, you place the thumb over the radial head, grab the wrist, supinate the forearm, and flex the elbow. However, the results of two randomized trials comparing supination with hyperpronation suggest that hyperpronation is superior. Instead of supinating and flexing, simply place the thumb over the radial head, grab the wrist, and slowly pronate.

In one study, 90 children received either supination and flexion or pronation as the first treatment, and the first-attempt success rate was significantly higher for the hyperpronation method (95% vs. 77%) (Pediatrics 1998;102:e10).

▸ A figure-of-eight dressing is a better treatment for a clavicle fracture than a simple sling.

The reality: Some physicians argue that the figure-of-eight makes sense because it may approximate any fracture fragments better than a sling. However, a study of 140 patients with a clavicle fracture who were treated with either a simple sling or figure-of-eight showed no difference in speed of recovery (Injury 1988;19:162–4).

▸ All shoulder dislocations need pre- and postreduction x-rays.

The reality: A shoulder dislocation is often so obvious that x-rays are unnecessary, although the textbook says to get one, Dr. Hendey said.

“There are now six studies in this area that say you don't need x-rays,” he said. One study of prereduction films showed that three clinical factors—age older than 40 years, first-time dislocation, or a traumatic injury—identify 98% of fractures (Acad. Emerg. Med. 2004; 11:853–8).

“If you aren't sure, of course you should x-ray it,” he said.

WASHINGTON — Recent orthopedic research challenges many standards of emergency orthopedics drawn from the archetypal textbook that every medical school uses, Gregory W. Hendey, M.D., said at the annual meeting of the American College of Emergency Physicians.

Dr. Hendey of the University of California, San Francisco, debunked several myths:

▸ Preoperative skin traction reduces the pain associated with hip fracture.

The reality: A Cochrane review from 2003 including eight randomized trials and 1,349 patients showed no benefit from either skin or skeletal traction, compared with no traction for preoperative hip-fracture pain relief.

No significant difference in pain was reported after the first night following the hip fracture in a study of 311 patients randomized to skin traction vs. no traction (Int. Orthop. 2002;26:361–4). To relieve the considerable pain that some of these patients experience, consider a femoral nerve block, advised Dr. Hendey, research director of the UCSF Fresno emergency medicine residency program. In a relatively small study, patients who received a nerve block used significantly fewer analgesics than did those who didn't receive the block.

▸ A scapula fracture is associated with life-threatening injuries and requires an extensive workup.

The reality: Previous studies have shown that a high percentage of patients with a scapula fracture have other problems, but these results may be caused by the use of trauma registries for patient selection.

In a study of 11,500 patients from two trauma centers, 92 patients with scapula fracture were compared with 81 matched controls. Although scapula fracture was significantly associated with thoracic injury (49% vs. 6%), there was no significant difference in mortality or neurovascular morbidity between the two groups (Ann. Emerg. Med. 1995;26:439–42).

▸ A boxer's fracture must be reduced and immobilized with an ulnar gutter splint.

The reality: Strength and alignment are similar in splinted and nonsplinted patients, according to several studies.

In a prospective study of 29 patients with subcapital fifth metacarpal fractures randomized to either reduction and splint or functional treatment, all the fractures healed well. The functional group recovered faster, however, with better strength and range of motion than the reduction and splint group (Scand. J. Plast. Reconstr. Surg. Hand. Surg. 1999;33:315–7).

▸ Nursemaid's elbow is best reduced with rapid supination and elbow flexion.

The reality: Most physicians learned that the way to reduce nursemaid's elbow is rapid supination and flexion. That method works, but there is a kinder, gentler way, Dr. Hendey said.

In supination, you place the thumb over the radial head, grab the wrist, supinate the forearm, and flex the elbow. However, the results of two randomized trials comparing supination with hyperpronation suggest that hyperpronation is superior. Instead of supinating and flexing, simply place the thumb over the radial head, grab the wrist, and slowly pronate.

In one study, 90 children received either supination and flexion or pronation as the first treatment, and the first-attempt success rate was significantly higher for the hyperpronation method (95% vs. 77%) (Pediatrics 1998;102:e10).

▸ A figure-of-eight dressing is a better treatment for a clavicle fracture than a simple sling.

The reality: Some physicians argue that the figure-of-eight makes sense because it may approximate any fracture fragments better than a sling. However, a study of 140 patients with a clavicle fracture who were treated with either a simple sling or figure-of-eight showed no difference in speed of recovery (Injury 1988;19:162–4).

▸ All shoulder dislocations need pre- and postreduction x-rays.

The reality: A shoulder dislocation is often so obvious that x-rays are unnecessary, although the textbook says to get one, Dr. Hendey said.

“There are now six studies in this area that say you don't need x-rays,” he said. One study of prereduction films showed that three clinical factors—age older than 40 years, first-time dislocation, or a traumatic injury—identify 98% of fractures (Acad. Emerg. Med. 2004; 11:853–8).

“If you aren't sure, of course you should x-ray it,” he said.

WASHINGTON — Recent orthopedic research challenges many standards of emergency orthopedics drawn from the archetypal textbook that every medical school uses, Gregory W. Hendey, M.D., said at the annual meeting of the American College of Emergency Physicians.

Dr. Hendey of the University of California, San Francisco, debunked several myths:

▸ Preoperative skin traction reduces the pain associated with hip fracture.

The reality: A Cochrane review from 2003 including eight randomized trials and 1,349 patients showed no benefit from either skin or skeletal traction, compared with no traction for preoperative hip-fracture pain relief.

No significant difference in pain was reported after the first night following the hip fracture in a study of 311 patients randomized to skin traction vs. no traction (Int. Orthop. 2002;26:361–4). To relieve the considerable pain that some of these patients experience, consider a femoral nerve block, advised Dr. Hendey, research director of the UCSF Fresno emergency medicine residency program. In a relatively small study, patients who received a nerve block used significantly fewer analgesics than did those who didn't receive the block.

▸ A scapula fracture is associated with life-threatening injuries and requires an extensive workup.

The reality: Previous studies have shown that a high percentage of patients with a scapula fracture have other problems, but these results may be caused by the use of trauma registries for patient selection.

In a study of 11,500 patients from two trauma centers, 92 patients with scapula fracture were compared with 81 matched controls. Although scapula fracture was significantly associated with thoracic injury (49% vs. 6%), there was no significant difference in mortality or neurovascular morbidity between the two groups (Ann. Emerg. Med. 1995;26:439–42).

▸ A boxer's fracture must be reduced and immobilized with an ulnar gutter splint.

The reality: Strength and alignment are similar in splinted and nonsplinted patients, according to several studies.

In a prospective study of 29 patients with subcapital fifth metacarpal fractures randomized to either reduction and splint or functional treatment, all the fractures healed well. The functional group recovered faster, however, with better strength and range of motion than the reduction and splint group (Scand. J. Plast. Reconstr. Surg. Hand. Surg. 1999;33:315–7).

▸ Nursemaid's elbow is best reduced with rapid supination and elbow flexion.

The reality: Most physicians learned that the way to reduce nursemaid's elbow is rapid supination and flexion. That method works, but there is a kinder, gentler way, Dr. Hendey said.

In supination, you place the thumb over the radial head, grab the wrist, supinate the forearm, and flex the elbow. However, the results of two randomized trials comparing supination with hyperpronation suggest that hyperpronation is superior. Instead of supinating and flexing, simply place the thumb over the radial head, grab the wrist, and slowly pronate.

In one study, 90 children received either supination and flexion or pronation as the first treatment, and the first-attempt success rate was significantly higher for the hyperpronation method (95% vs. 77%) (Pediatrics 1998;102:e10).

▸ A figure-of-eight dressing is a better treatment for a clavicle fracture than a simple sling.

The reality: Some physicians argue that the figure-of-eight makes sense because it may approximate any fracture fragments better than a sling. However, a study of 140 patients with a clavicle fracture who were treated with either a simple sling or figure-of-eight showed no difference in speed of recovery (Injury 1988;19:162–4).

▸ All shoulder dislocations need pre- and postreduction x-rays.

The reality: A shoulder dislocation is often so obvious that x-rays are unnecessary, although the textbook says to get one, Dr. Hendey said.

“There are now six studies in this area that say you don't need x-rays,” he said. One study of prereduction films showed that three clinical factors—age older than 40 years, first-time dislocation, or a traumatic injury—identify 98% of fractures (Acad. Emerg. Med. 2004; 11:853–8).

“If you aren't sure, of course you should x-ray it,” he said.

BALTIMORE — Consider a wide range of causes when evaluating a child for a growth disorder, Leslie Plotnick, M.D., said at a meeting on pediatric endocrinology sponsored by Johns Hopkins University.

Although growth hormone treatment is approved by the Food and Drug Administration for some conditions, not all children with growth problems are growth hormone deficient, and a thorough evaluation is important, including a complete history and physical examination.

“A child with normal growth will track along a percentile line,” said Dr. Plotnick, a pediatric endocrinologist at Johns Hopkins University. Growth velocity normally decreases prior to puberty, until the adolescent growth spurt begins.

Consider evaluating children for growth problems when the growth rate is less than 5 cm/yr from age 3 years to 12 years, Dr. Plotnick advised. In addition, consider the possibility of a growth disorder when a child's height is below the 5th percentile or when height drops across percentiles over time. Another sign is when a child's height is more than two standard deviations below the average height of the biologic parents.

Causes of short stature or poor linear growth include major organ system diseases that are cardiac, pulmonary, renal, gastrointestinal, nutritional, hematologic, or CNS-related. In addition, chromosomal disorders such as Turner's syndrome; intrauterine growth retardation; endocrine disorders; or, simply, familial short stature or constitutional growth delay can cause a child to grow at a slower than average rate.

Although evidence of any association remains uncertain, oral or inhaled glucocorticoids might contribute to delayed growth. Long-term data on the impact of other medications—including stimulants, antidepressants, antiseizure medications, and antipsychotics—on growth delay remain inconclusive as well.

Carefully monitor height and weight patterns in children who take these medications, Dr. Plotnick said. Changes from established pretreatment growth patterns suggest a medication effect and may require further evaluation.

Endocrine-related causes of short stature include hypothyroidism, cortisol excess, pseudohypoparathyroidism, poorly controlled diabetes mellitus, and growth hormone deficiency. Features associated with these conditions include goiter, dry skin, midline defects, micropenis in boys, and an especially round, cherubic face.

The screening work-up for short stature is extensive and includes a complete metabolic profile, complete blood count, thyroid function test, and celiac screen.

A definitive diagnosis of growth hormone deficiency requires at least two tests that indicate a growth hormone level of less than 10 ng/mL, including arginine, L-dopa, clonidine, glucagon, and insulin-induced hypoglycemia. If a child appears to have growth hormone deficiency, conduct a brain MRI and test other pituitary axis hormones, she added.

Growth hormone deficiency can be congenital or genetic, or it can be acquired as a result of brain tumors, infiltrative diseases, head trauma, infection, central nervous system surgery, or central nervous system irradiation to treat a tumor.

For more specific information about growth patterns in children and to download the current growth charts from the Centers for Disease Control and Prevention, visit www.cdc.gov/growthcharts

BALTIMORE — Consider a wide range of causes when evaluating a child for a growth disorder, Leslie Plotnick, M.D., said at a meeting on pediatric endocrinology sponsored by Johns Hopkins University.

Although growth hormone treatment is approved by the Food and Drug Administration for some conditions, not all children with growth problems are growth hormone deficient, and a thorough evaluation is important, including a complete history and physical examination.

“A child with normal growth will track along a percentile line,” said Dr. Plotnick, a pediatric endocrinologist at Johns Hopkins University. Growth velocity normally decreases prior to puberty, until the adolescent growth spurt begins.

Consider evaluating children for growth problems when the growth rate is less than 5 cm/yr from age 3 years to 12 years, Dr. Plotnick advised. In addition, consider the possibility of a growth disorder when a child's height is below the 5th percentile or when height drops across percentiles over time. Another sign is when a child's height is more than two standard deviations below the average height of the biologic parents.

Causes of short stature or poor linear growth include major organ system diseases that are cardiac, pulmonary, renal, gastrointestinal, nutritional, hematologic, or CNS-related. In addition, chromosomal disorders such as Turner's syndrome; intrauterine growth retardation; endocrine disorders; or, simply, familial short stature or constitutional growth delay can cause a child to grow at a slower than average rate.

Although evidence of any association remains uncertain, oral or inhaled glucocorticoids might contribute to delayed growth. Long-term data on the impact of other medications—including stimulants, antidepressants, antiseizure medications, and antipsychotics—on growth delay remain inconclusive as well.

Carefully monitor height and weight patterns in children who take these medications, Dr. Plotnick said. Changes from established pretreatment growth patterns suggest a medication effect and may require further evaluation.

Endocrine-related causes of short stature include hypothyroidism, cortisol excess, pseudohypoparathyroidism, poorly controlled diabetes mellitus, and growth hormone deficiency. Features associated with these conditions include goiter, dry skin, midline defects, micropenis in boys, and an especially round, cherubic face.

The screening work-up for short stature is extensive and includes a complete metabolic profile, complete blood count, thyroid function test, and celiac screen.

A definitive diagnosis of growth hormone deficiency requires at least two tests that indicate a growth hormone level of less than 10 ng/mL, including arginine, L-dopa, clonidine, glucagon, and insulin-induced hypoglycemia. If a child appears to have growth hormone deficiency, conduct a brain MRI and test other pituitary axis hormones, she added.

Growth hormone deficiency can be congenital or genetic, or it can be acquired as a result of brain tumors, infiltrative diseases, head trauma, infection, central nervous system surgery, or central nervous system irradiation to treat a tumor.

For more specific information about growth patterns in children and to download the current growth charts from the Centers for Disease Control and Prevention, visit www.cdc.gov/growthcharts

BALTIMORE — Consider a wide range of causes when evaluating a child for a growth disorder, Leslie Plotnick, M.D., said at a meeting on pediatric endocrinology sponsored by Johns Hopkins University.

Although growth hormone treatment is approved by the Food and Drug Administration for some conditions, not all children with growth problems are growth hormone deficient, and a thorough evaluation is important, including a complete history and physical examination.

“A child with normal growth will track along a percentile line,” said Dr. Plotnick, a pediatric endocrinologist at Johns Hopkins University. Growth velocity normally decreases prior to puberty, until the adolescent growth spurt begins.

Consider evaluating children for growth problems when the growth rate is less than 5 cm/yr from age 3 years to 12 years, Dr. Plotnick advised. In addition, consider the possibility of a growth disorder when a child's height is below the 5th percentile or when height drops across percentiles over time. Another sign is when a child's height is more than two standard deviations below the average height of the biologic parents.

Causes of short stature or poor linear growth include major organ system diseases that are cardiac, pulmonary, renal, gastrointestinal, nutritional, hematologic, or CNS-related. In addition, chromosomal disorders such as Turner's syndrome; intrauterine growth retardation; endocrine disorders; or, simply, familial short stature or constitutional growth delay can cause a child to grow at a slower than average rate.

Although evidence of any association remains uncertain, oral or inhaled glucocorticoids might contribute to delayed growth. Long-term data on the impact of other medications—including stimulants, antidepressants, antiseizure medications, and antipsychotics—on growth delay remain inconclusive as well.

Carefully monitor height and weight patterns in children who take these medications, Dr. Plotnick said. Changes from established pretreatment growth patterns suggest a medication effect and may require further evaluation.

Endocrine-related causes of short stature include hypothyroidism, cortisol excess, pseudohypoparathyroidism, poorly controlled diabetes mellitus, and growth hormone deficiency. Features associated with these conditions include goiter, dry skin, midline defects, micropenis in boys, and an especially round, cherubic face.

The screening work-up for short stature is extensive and includes a complete metabolic profile, complete blood count, thyroid function test, and celiac screen.

A definitive diagnosis of growth hormone deficiency requires at least two tests that indicate a growth hormone level of less than 10 ng/mL, including arginine, L-dopa, clonidine, glucagon, and insulin-induced hypoglycemia. If a child appears to have growth hormone deficiency, conduct a brain MRI and test other pituitary axis hormones, she added.

Growth hormone deficiency can be congenital or genetic, or it can be acquired as a result of brain tumors, infiltrative diseases, head trauma, infection, central nervous system surgery, or central nervous system irradiation to treat a tumor.

For more specific information about growth patterns in children and to download the current growth charts from the Centers for Disease Control and Prevention, visit www.cdc.gov/growthcharts

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were those who had the resistance tests. “Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies show conflicting results on the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were those who had the resistance tests. “Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies show conflicting results on the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

BETHESDA, MD. — Drug resistance poses a problem in treating HIV patients, in part because of the virus's high mutation rate, Roy M. Gulick, M.D., said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Factors affecting HIV drug resistance include the virus itself, the antiretroviral drugs used, and the characteristics of the individual patient. Drug resistance is one of the main reasons why HIV treatments fail, said Dr. Gulick, director of the Cornell HIV Clinical Trials Unit at Weill Medical College of Cornell University, New York.

The goal of antiretroviral therapy (ART) is to suppress the viral load to as low a level as possible for as long as possible, he noted. Due to the high rate of mutation in the HIV virus, viral diversity is extensive. Failure to suppress viral load levels in the presence of antiretroviral drugs leads to the development of a resistant strain, Dr. Gulick explained.

Patient-related factors that can contribute to the development of resistance include the stage of disease, use of other medications, medication adherence, and side effects.

“We used to follow resistance clinically. If someone was taking their drugs, and their viral load went down, but then rose again, if we were sure that they were taking the medication, we assumed that they had developed resistance,” he said. Today, genotypic tests provide viral sequencing of a patient's viral strain, and phenotypic tests can grow the patient's virus in vitro and assess resistance in the presence of the available antiretroviral drugs.

Are resistance tests clinically valuable? Dr. Gulick cited three studies, including one published in the Lancet, in which several hundred patients who had failed drug therapies were randomized to either genotypic or phenotypic drug resistance testing or standard care (Lancet 1999;353:2195–9).

Overall, the patients who fared better in terms of viral load reduction on their new regimens were those who had the resistance tests. “Simply put, resistance tests help clinicians choose active drugs for the next regimen,” Dr. Gulick said. Guidelines from the Department of Health and Human Services recommend resistance tests in the clinical setting in cases of virologic failure, suboptimal virologic suppression, and acute HIV infection.

These tests could be considered in cases of HIV infection before starting ART, but they are generally not recommended for patients more than 4 weeks after ART drug use ends, or when viral load levels are less than 1,000 copies per million.

However, studies of the effectiveness of resistance testing are limited by several factors, including problems with the clinical cutoffs—when the drugs lose activity over time—and questions as to whether the studies had enrolled patients who had failed multiple treatments.

Other studies show conflicting results on the use of resistance tests, especially for highly resistant patients. “The best resistance tests can't help a patient if they have no drug options to go to,” Dr. Gulick said.

Asked whether he recommends genotypic or phenotypic testing for patients who are just starting antiretroviral therapy or who already have resistance, Dr. Gulick commented that although sufficient clinical evidence is lacking, most experts recommend a genotype test for patients who are treatment naive or have failed their first regimen, when it is relatively easy to figure out what the mutations mean. But in patients who have been through multiple regimens, phenotype is easier to interpret.

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

Norovirus Locates Katrina Evacuees

An outbreak of norovirus occurred from Sept. 2–12, 2005, among evacuees from Hurricane Katrina who were temporarily sheltered at Reliant Park, a recreation and convention complex in Houston. During this period, about 6,500 of an estimated 24,000 evacuees visited the Reliant Park medical clinic, and 1,169 (18%) reported symptoms of acute gastroenteritis; one-quarter were younger than 18 years of age. The peak occurred on Sept. 5, when 211 people reported acute GI symptoms. During peak days, about 40% of pediatric visits and 21% of adult visits to the clinic were related to acute gastroenteritis, according to a report from the Centers for Disease Control and Prevention in Atlanta (MMWR 2005:54;1016–8). Samples from 44 patients were tested, and 22 (50%) of these yielded norovirus; no other enteropathogen was identified. Norovirus is highly contagious and transmissible in crowded conditions. Overall, 511 (44%) of those with acute symptoms had diarrhea only, while 342 (29%) reported vomiting, and 316 (27%) reported both vomiting and diarrhea. Local health authorities implemented preventive measures at the start of the outbreak, including placing patients with suspected illness in a separate observation area, then placing them in an isolation area for at least 48 hours after the abatement of symptoms. Also, more sinks and hand sanitizers were installed. Still, the outbreak continued for at least a week.

Amoxicillin Ups Fluorosis Risk

Use of amoxicillin in the first 6 months may increase the risk of fluorosis in permanent teeth, said Liang Hong, D.D.S., formerly of the University of Iowa in Iowa City, and associates. Dr. Hong, currently of the University of Missouri, Kansas City, and colleagues conducted a longitudinal study of 579 children to assess the possible impact of amoxicillin use in infancy on tooth enamel at a mean age of 9 years (Arch. Pediatr. Adolesc. Med. 2005;159:943–8). After controlling for fluoride intake and otitis media (OM), the risk of fluorosis on the maxillary central incisors was significantly associated with amoxicillin use from 3–6 months of age, with a risk ratio of 1.85. OM accounted for 60%–82% of reported illnesses in the group, and amoxicillin accounted for 73%–85% of the antibiotics given to treat OM in the first year of life. However, given the presence of fluorosis in teeth long before the introduction of amoxicillin, more data are needed, and current pediatric practice is unlikely to change as a result of the study, Paul S. Casamassimo, D.D.S., of the Ohio State University, Columbus, said in an accompanying editorial (Arch. Pediatr. Adolesc. Med.;159:995–6).

HPV Transmits Nonsexually

Anogenital warts in children with human papillomavirus were less predictive of sexual abuse with decreasing age, based on a review of 124 children younger than 13 years with anogenital and respiratory tract human papillomavirus (HPV) infections, said Kelly A. Sinclair, M.D., formerly of Wake Forest University, Winston-Salem, N.C., and her colleagues. Of these, 55 with anogenital warts were evaluated at a childhood sexual abuse clinic, and 17 (31%) were considered to have been abused. Children younger than 4 years were 3 times less likely to have been sexually abused than those aged 4–8 years, and those younger than 4 years were 12 times less likely to have been abused than those older than 8 years. These findings challenge the notion that 24 months of age is the upper limit for perinatal transmission of anogenital warts. None of the 49 children evaluated for laryngeal or oral lesions were considered to have been sexually abused, and the onset of illness peaked at 2–5 years. Since the majority of preadolescent anogenital HPV cases are older than 2 years, the use of 2 years as a cutoff to cite sexual abuse as the cause of infection could subject innocent families to unnecessary scrutiny, said Dr. Sinclair, currently at Children's Mercy Hospital, Kansas City, Mo., and her associates.

UTI Prophylaxis Choices

Children who received prophylactic antibiotics for urinary tract infections were significantly more resistant to third-generation cephalosporins, compared with those who didn't receive prophylaxis, said Stephanie A. Lutter, M.D., and colleagues at the Medical College of Wisconsin, Milwaukee (Arch. Pediatr. Adolesc. Med. 2005;159:924–8). The study included 361 children younger than 18 (mean age 31 months) with UTIs. Cefotaxime resistance occurred in 7 of 26 (27%) children who received antibiotic prophylaxis for urinary tract infections, compared with 9 of 335 (3%) children who did not. Escherichia coli accounted for 87% of all infections, but 58% of the infections in those who received prophylaxis. Overall resistance to aminoglycosides was 1%, which makes them more appropriate antibiotics for children treated prophylactically, they said.

Norovirus Locates Katrina Evacuees

An outbreak of norovirus occurred from Sept. 2–12, 2005, among evacuees from Hurricane Katrina who were temporarily sheltered at Reliant Park, a recreation and convention complex in Houston. During this period, about 6,500 of an estimated 24,000 evacuees visited the Reliant Park medical clinic, and 1,169 (18%) reported symptoms of acute gastroenteritis; one-quarter were younger than 18 years of age. The peak occurred on Sept. 5, when 211 people reported acute GI symptoms. During peak days, about 40% of pediatric visits and 21% of adult visits to the clinic were related to acute gastroenteritis, according to a report from the Centers for Disease Control and Prevention in Atlanta (MMWR 2005:54;1016–8). Samples from 44 patients were tested, and 22 (50%) of these yielded norovirus; no other enteropathogen was identified. Norovirus is highly contagious and transmissible in crowded conditions. Overall, 511 (44%) of those with acute symptoms had diarrhea only, while 342 (29%) reported vomiting, and 316 (27%) reported both vomiting and diarrhea. Local health authorities implemented preventive measures at the start of the outbreak, including placing patients with suspected illness in a separate observation area, then placing them in an isolation area for at least 48 hours after the abatement of symptoms. Also, more sinks and hand sanitizers were installed. Still, the outbreak continued for at least a week.

Amoxicillin Ups Fluorosis Risk

Use of amoxicillin in the first 6 months may increase the risk of fluorosis in permanent teeth, said Liang Hong, D.D.S., formerly of the University of Iowa in Iowa City, and associates. Dr. Hong, currently of the University of Missouri, Kansas City, and colleagues conducted a longitudinal study of 579 children to assess the possible impact of amoxicillin use in infancy on tooth enamel at a mean age of 9 years (Arch. Pediatr. Adolesc. Med. 2005;159:943–8). After controlling for fluoride intake and otitis media (OM), the risk of fluorosis on the maxillary central incisors was significantly associated with amoxicillin use from 3–6 months of age, with a risk ratio of 1.85. OM accounted for 60%–82% of reported illnesses in the group, and amoxicillin accounted for 73%–85% of the antibiotics given to treat OM in the first year of life. However, given the presence of fluorosis in teeth long before the introduction of amoxicillin, more data are needed, and current pediatric practice is unlikely to change as a result of the study, Paul S. Casamassimo, D.D.S., of the Ohio State University, Columbus, said in an accompanying editorial (Arch. Pediatr. Adolesc. Med.;159:995–6).

HPV Transmits Nonsexually

Anogenital warts in children with human papillomavirus were less predictive of sexual abuse with decreasing age, based on a review of 124 children younger than 13 years with anogenital and respiratory tract human papillomavirus (HPV) infections, said Kelly A. Sinclair, M.D., formerly of Wake Forest University, Winston-Salem, N.C., and her colleagues. Of these, 55 with anogenital warts were evaluated at a childhood sexual abuse clinic, and 17 (31%) were considered to have been abused. Children younger than 4 years were 3 times less likely to have been sexually abused than those aged 4–8 years, and those younger than 4 years were 12 times less likely to have been abused than those older than 8 years. These findings challenge the notion that 24 months of age is the upper limit for perinatal transmission of anogenital warts. None of the 49 children evaluated for laryngeal or oral lesions were considered to have been sexually abused, and the onset of illness peaked at 2–5 years. Since the majority of preadolescent anogenital HPV cases are older than 2 years, the use of 2 years as a cutoff to cite sexual abuse as the cause of infection could subject innocent families to unnecessary scrutiny, said Dr. Sinclair, currently at Children's Mercy Hospital, Kansas City, Mo., and her associates.

UTI Prophylaxis Choices

Children who received prophylactic antibiotics for urinary tract infections were significantly more resistant to third-generation cephalosporins, compared with those who didn't receive prophylaxis, said Stephanie A. Lutter, M.D., and colleagues at the Medical College of Wisconsin, Milwaukee (Arch. Pediatr. Adolesc. Med. 2005;159:924–8). The study included 361 children younger than 18 (mean age 31 months) with UTIs. Cefotaxime resistance occurred in 7 of 26 (27%) children who received antibiotic prophylaxis for urinary tract infections, compared with 9 of 335 (3%) children who did not. Escherichia coli accounted for 87% of all infections, but 58% of the infections in those who received prophylaxis. Overall resistance to aminoglycosides was 1%, which makes them more appropriate antibiotics for children treated prophylactically, they said.

Norovirus Locates Katrina Evacuees

An outbreak of norovirus occurred from Sept. 2–12, 2005, among evacuees from Hurricane Katrina who were temporarily sheltered at Reliant Park, a recreation and convention complex in Houston. During this period, about 6,500 of an estimated 24,000 evacuees visited the Reliant Park medical clinic, and 1,169 (18%) reported symptoms of acute gastroenteritis; one-quarter were younger than 18 years of age. The peak occurred on Sept. 5, when 211 people reported acute GI symptoms. During peak days, about 40% of pediatric visits and 21% of adult visits to the clinic were related to acute gastroenteritis, according to a report from the Centers for Disease Control and Prevention in Atlanta (MMWR 2005:54;1016–8). Samples from 44 patients were tested, and 22 (50%) of these yielded norovirus; no other enteropathogen was identified. Norovirus is highly contagious and transmissible in crowded conditions. Overall, 511 (44%) of those with acute symptoms had diarrhea only, while 342 (29%) reported vomiting, and 316 (27%) reported both vomiting and diarrhea. Local health authorities implemented preventive measures at the start of the outbreak, including placing patients with suspected illness in a separate observation area, then placing them in an isolation area for at least 48 hours after the abatement of symptoms. Also, more sinks and hand sanitizers were installed. Still, the outbreak continued for at least a week.

Amoxicillin Ups Fluorosis Risk

Use of amoxicillin in the first 6 months may increase the risk of fluorosis in permanent teeth, said Liang Hong, D.D.S., formerly of the University of Iowa in Iowa City, and associates. Dr. Hong, currently of the University of Missouri, Kansas City, and colleagues conducted a longitudinal study of 579 children to assess the possible impact of amoxicillin use in infancy on tooth enamel at a mean age of 9 years (Arch. Pediatr. Adolesc. Med. 2005;159:943–8). After controlling for fluoride intake and otitis media (OM), the risk of fluorosis on the maxillary central incisors was significantly associated with amoxicillin use from 3–6 months of age, with a risk ratio of 1.85. OM accounted for 60%–82% of reported illnesses in the group, and amoxicillin accounted for 73%–85% of the antibiotics given to treat OM in the first year of life. However, given the presence of fluorosis in teeth long before the introduction of amoxicillin, more data are needed, and current pediatric practice is unlikely to change as a result of the study, Paul S. Casamassimo, D.D.S., of the Ohio State University, Columbus, said in an accompanying editorial (Arch. Pediatr. Adolesc. Med.;159:995–6).

HPV Transmits Nonsexually

Anogenital warts in children with human papillomavirus were less predictive of sexual abuse with decreasing age, based on a review of 124 children younger than 13 years with anogenital and respiratory tract human papillomavirus (HPV) infections, said Kelly A. Sinclair, M.D., formerly of Wake Forest University, Winston-Salem, N.C., and her colleagues. Of these, 55 with anogenital warts were evaluated at a childhood sexual abuse clinic, and 17 (31%) were considered to have been abused. Children younger than 4 years were 3 times less likely to have been sexually abused than those aged 4–8 years, and those younger than 4 years were 12 times less likely to have been abused than those older than 8 years. These findings challenge the notion that 24 months of age is the upper limit for perinatal transmission of anogenital warts. None of the 49 children evaluated for laryngeal or oral lesions were considered to have been sexually abused, and the onset of illness peaked at 2–5 years. Since the majority of preadolescent anogenital HPV cases are older than 2 years, the use of 2 years as a cutoff to cite sexual abuse as the cause of infection could subject innocent families to unnecessary scrutiny, said Dr. Sinclair, currently at Children's Mercy Hospital, Kansas City, Mo., and her associates.

UTI Prophylaxis Choices

Children who received prophylactic antibiotics for urinary tract infections were significantly more resistant to third-generation cephalosporins, compared with those who didn't receive prophylaxis, said Stephanie A. Lutter, M.D., and colleagues at the Medical College of Wisconsin, Milwaukee (Arch. Pediatr. Adolesc. Med. 2005;159:924–8). The study included 361 children younger than 18 (mean age 31 months) with UTIs. Cefotaxime resistance occurred in 7 of 26 (27%) children who received antibiotic prophylaxis for urinary tract infections, compared with 9 of 335 (3%) children who did not. Escherichia coli accounted for 87% of all infections, but 58% of the infections in those who received prophylaxis. Overall resistance to aminoglycosides was 1%, which makes them more appropriate antibiotics for children treated prophylactically, they said.

Three children diagnosed with Waterhouse-Friderichsen syndrome died after rapidly progressive illness was traced to severe Staphylococcus aureus infection, said Patricia V. Adem, M.D., of the University of Chicago, and her associates.

The three patients—a 15-month-old girl, a 9-month-old girl, and a 17-month-old boy—had been in good health prior to the onset of infection. Premortem cultures yielded methicillin-susceptible S. aureus in the first patient and methicillin-resistant S. aureus (MRSA) in the next two patients. All the isolates were genetically related, which underscores the rise in community-associated MRSA, the investigators said (N. Engl. J. Med. 2005;353:1245–51).

Characteristics of Waterhouse-Friderichsen syndrome include petechial rash, coagulopathy, cardiovascular collapse, and bilateral adrenal hemorrhage. Although extracorporeal membrane oxygenation has been associated with adrenal hemorrhage in other studies, it was not associated with fatal illness in the two patients in this review who received it.

Noteworthy clinical features in all three children included leukopenia, neutropenia, profound tachycardia, and profound metabolic acidosis, and the course of the disease resembled fulminant meningococcemia.

Pathologic findings revealed severe sepsis and disseminated intravascular coagulation, but there was no evidence of myocarditis or endocarditis. The lungs of all three patients showed gram-positive cocci in clusters, some of which were found in the vascular walls.

Three children diagnosed with Waterhouse-Friderichsen syndrome died after rapidly progressive illness was traced to severe Staphylococcus aureus infection, said Patricia V. Adem, M.D., of the University of Chicago, and her associates.

The three patients—a 15-month-old girl, a 9-month-old girl, and a 17-month-old boy—had been in good health prior to the onset of infection. Premortem cultures yielded methicillin-susceptible S. aureus in the first patient and methicillin-resistant S. aureus (MRSA) in the next two patients. All the isolates were genetically related, which underscores the rise in community-associated MRSA, the investigators said (N. Engl. J. Med. 2005;353:1245–51).

Characteristics of Waterhouse-Friderichsen syndrome include petechial rash, coagulopathy, cardiovascular collapse, and bilateral adrenal hemorrhage. Although extracorporeal membrane oxygenation has been associated with adrenal hemorrhage in other studies, it was not associated with fatal illness in the two patients in this review who received it.

Noteworthy clinical features in all three children included leukopenia, neutropenia, profound tachycardia, and profound metabolic acidosis, and the course of the disease resembled fulminant meningococcemia.

Pathologic findings revealed severe sepsis and disseminated intravascular coagulation, but there was no evidence of myocarditis or endocarditis. The lungs of all three patients showed gram-positive cocci in clusters, some of which were found in the vascular walls.

Three children diagnosed with Waterhouse-Friderichsen syndrome died after rapidly progressive illness was traced to severe Staphylococcus aureus infection, said Patricia V. Adem, M.D., of the University of Chicago, and her associates.

The three patients—a 15-month-old girl, a 9-month-old girl, and a 17-month-old boy—had been in good health prior to the onset of infection. Premortem cultures yielded methicillin-susceptible S. aureus in the first patient and methicillin-resistant S. aureus (MRSA) in the next two patients. All the isolates were genetically related, which underscores the rise in community-associated MRSA, the investigators said (N. Engl. J. Med. 2005;353:1245–51).

Characteristics of Waterhouse-Friderichsen syndrome include petechial rash, coagulopathy, cardiovascular collapse, and bilateral adrenal hemorrhage. Although extracorporeal membrane oxygenation has been associated with adrenal hemorrhage in other studies, it was not associated with fatal illness in the two patients in this review who received it.

Noteworthy clinical features in all three children included leukopenia, neutropenia, profound tachycardia, and profound metabolic acidosis, and the course of the disease resembled fulminant meningococcemia.

Pathologic findings revealed severe sepsis and disseminated intravascular coagulation, but there was no evidence of myocarditis or endocarditis. The lungs of all three patients showed gram-positive cocci in clusters, some of which were found in the vascular walls.