Heidi Splete

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

Existential issues were significantly correlated with the will to live in a study of 189 end-stage cancer patients.

Harvey Max Chochinov, M.D., professor of psychiatry at the University of Manitoba (Canada), and his colleagues examined the simultaneous influences of existential, psychiatric, and physical issues on the will to live in terminally ill patients (Psychosomatics 2005;46:7–10).

In a multiple regression analysis, each of the existential issues assessed–hopelessness, sense of dignity, and being a burden to others–was significantly correlated with the will to live.

In addition, psychiatric issues such as depression, anxiety, and concentration were significantly associated with the will to live. Social variables–including support from family friends and health care providers, and patient satisfaction with this support–also were significantly correlated with the will to live.

Physical issues, particularly dyspnea, appetite, and appearance, were significantly correlated as well, but to a lesser degree than were existential, psychiatric, and social issues.

The patients, who were recruited from two Canadian palliative care facilities, shared information about their end-of-life experiences, which were rated on a symptom distress scale developed for cancer patients and an index of independence in activities of daily living. The mean age of patients was 69 years, and almost half were men. The most common cancers were lung (29%), gastrointestinal tract (26%), genitourinary system (16%), and breast (15%).

In a univariate analysis, hopelessness was highly predictive of suicidal ideation, as was a feeling of being a burden to others and a wish to die with dignity. The inclusion of dignity in the model suggests that patients who lose their sense of self and feel that their lives are no longer valued have less will to live. “It would appear that losing one's sense of meaning and purpose–experiencing life as having become redundant or futile–is an important existential underpinning of the loss of will to live among the dying,” Dr. Chochinov and his associates noted.

Although the study was limited by its focus on cancer patients, the results highlight the need to examine the factors driving terminal patients' wills to live in order to provide appropriate palliative care. The study was supported in part by the National Cancer Institute of Canada.

ADHD Can Arise After Head Injuries

Secondary attention-deficit hyperactivity disorder was diagnosed in 15 of 103 children (15%) aged 5–14 years who were assessed 12 months after a traumatic head injury, said Jeffrey E. Max, M.B., of the University of California, San Diego, and his colleagues.

Secondary ADHD was significantly associated with several new-onset disorders, such as personality change, 6–12 months after the injury. Of 82 children who returned after 24 months, 17 (21%) were diagnosed with secondary ADHD, and many of the same new-onset conditions remained (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1041–9).

Children with lower preinjury adaptive function and greater preinjury psychosocial adversity were more likely to develop secondary ADHD. But the condition was not associated with age, sex, preinjury psychiatric disorder, or family psychiatric history.

Popular Ethnic Students Likely to Smoke

Popular nonwhite middle-school students were significantly more likely to smoke than were less popular peers, according to data from 1,486 sixth- and seventh-grade children in 16 southern California schools, said Thomas W. Valente, Ph.D., and his associates at the University of Southern California, Alhambra.

The ethnic makeup of the schools was primarily Hispanic and Asian; when classified as white or nonwhite, the association between popularity and smoking was significant among nonwhite children only. Popularity was associated with increased smoking by an adjusted odds ratio of 5.1 and with an increased susceptibility to smoking by an adjusted odds ratio of 5.6 (J. Adolesc. Health 2005;37:323–9). Popularity was assessed by asking students to name their closest friends and to name students who would be good leaders for a classroom project.

Bipolarity Affects Bowel Behavior

Encopresis and enuresis were more common in a cohort of 93 children and adolescents aged 7–16 years with early adolescent bipolar disorder I phenotype, compared with 81 children with ADHD and 94 healthy controls, wrote Tricia Klages and her colleagues at Washington University in St. Louis.

There were no significant differences in age, gender, or pubertal status among the groups. Encopresis (15% vs. 3%) and enuresis (22% vs. 6%) were significantly more common among prepubertal and early adolescent bipolar disorder I phenotype (PEA-BP) children compared with healthy controls. Although both conditions were more prevalent among PEA-BP children compared with ADHD children, the differences were not statistically significant (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1050–7). Maternal hostility appeared to be a significant factor; it was noted for 59% of subjects overall, and was significantly more common in children with encopresis than with nonencopretic children (92% vs. 56%).

Teen Opioid Treatments Compared

A combination of buprenorphine and behavioral intervention was significantly more effective than clonidine and behavioral intervention for the treatment of opioid dependence in adolescents, said Lisa A. Marsch, Ph.D.–who conducted the study while at the University of Vermont, Burlington–and her colleagues.

The randomized, double-blind, controlled study lasted for 28 days and included 36 adolescents aged 13–18 years who met the DSM-IV criteria for opioid dependence (Arch. Gen. Psychiatry 2005;62:1157–64). The flexible dosing procedure was based on weight and self-reported opioid use. Overall, significantly more adolescents in the buprenorphine group stayed in treatment (72%), compared with the clonidine group (39%). In addition, 61% of the buprenorphine group participated in the naltrexone phase of the study, which required three opioid-negative urine samples within a week, compared with 5% of the clonidine group.

CBT Benefits Endure for OCD Patients

Cognitive-behavioral therapy provided relief for children and adolescents with obsessive-compulsive disorder at 12–18 months' follow-up, said Paula Barrett, Ph.D., of Griffith University in Brisbane, Australia, and her associates. In a study of 48 participants aged 8–19 years, 70% of those in individual therapy and 84% of those in group therapy were free of OCD diagnosis at 12 months (J. Am. Acad. Child. Adolesc. Psychiatry 2005;44:1005–14). There were no significant changes in these numbers at 18 months, which suggests that children who were diagnosis free at the end of the treatment period tended to remain healthy.

Most of the patients (83%) received no additional treatment, including therapy or medication, in the time between the end of the CBT program and follow-up.

ADHD Can Arise After Head Injuries

Secondary attention-deficit hyperactivity disorder was diagnosed in 15 of 103 children (15%) aged 5–14 years who were assessed 12 months after a traumatic head injury, said Jeffrey E. Max, M.B., of the University of California, San Diego, and his colleagues.

Secondary ADHD was significantly associated with several new-onset disorders, such as personality change, 6–12 months after the injury. Of 82 children who returned after 24 months, 17 (21%) were diagnosed with secondary ADHD, and many of the same new-onset conditions remained (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1041–9).

Children with lower preinjury adaptive function and greater preinjury psychosocial adversity were more likely to develop secondary ADHD. But the condition was not associated with age, sex, preinjury psychiatric disorder, or family psychiatric history.

Popular Ethnic Students Likely to Smoke

Popular nonwhite middle-school students were significantly more likely to smoke than were less popular peers, according to data from 1,486 sixth- and seventh-grade children in 16 southern California schools, said Thomas W. Valente, Ph.D., and his associates at the University of Southern California, Alhambra.

The ethnic makeup of the schools was primarily Hispanic and Asian; when classified as white or nonwhite, the association between popularity and smoking was significant among nonwhite children only. Popularity was associated with increased smoking by an adjusted odds ratio of 5.1 and with an increased susceptibility to smoking by an adjusted odds ratio of 5.6 (J. Adolesc. Health 2005;37:323–9). Popularity was assessed by asking students to name their closest friends and to name students who would be good leaders for a classroom project.

Bipolarity Affects Bowel Behavior

Encopresis and enuresis were more common in a cohort of 93 children and adolescents aged 7–16 years with early adolescent bipolar disorder I phenotype, compared with 81 children with ADHD and 94 healthy controls, wrote Tricia Klages and her colleagues at Washington University in St. Louis.

There were no significant differences in age, gender, or pubertal status among the groups. Encopresis (15% vs. 3%) and enuresis (22% vs. 6%) were significantly more common among prepubertal and early adolescent bipolar disorder I phenotype (PEA-BP) children compared with healthy controls. Although both conditions were more prevalent among PEA-BP children compared with ADHD children, the differences were not statistically significant (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1050–7). Maternal hostility appeared to be a significant factor; it was noted for 59% of subjects overall, and was significantly more common in children with encopresis than with nonencopretic children (92% vs. 56%).

Teen Opioid Treatments Compared

A combination of buprenorphine and behavioral intervention was significantly more effective than clonidine and behavioral intervention for the treatment of opioid dependence in adolescents, said Lisa A. Marsch, Ph.D.–who conducted the study while at the University of Vermont, Burlington–and her colleagues.

The randomized, double-blind, controlled study lasted for 28 days and included 36 adolescents aged 13–18 years who met the DSM-IV criteria for opioid dependence (Arch. Gen. Psychiatry 2005;62:1157–64). The flexible dosing procedure was based on weight and self-reported opioid use. Overall, significantly more adolescents in the buprenorphine group stayed in treatment (72%), compared with the clonidine group (39%). In addition, 61% of the buprenorphine group participated in the naltrexone phase of the study, which required three opioid-negative urine samples within a week, compared with 5% of the clonidine group.

CBT Benefits Endure for OCD Patients

Cognitive-behavioral therapy provided relief for children and adolescents with obsessive-compulsive disorder at 12–18 months' follow-up, said Paula Barrett, Ph.D., of Griffith University in Brisbane, Australia, and her associates. In a study of 48 participants aged 8–19 years, 70% of those in individual therapy and 84% of those in group therapy were free of OCD diagnosis at 12 months (J. Am. Acad. Child. Adolesc. Psychiatry 2005;44:1005–14). There were no significant changes in these numbers at 18 months, which suggests that children who were diagnosis free at the end of the treatment period tended to remain healthy.

Most of the patients (83%) received no additional treatment, including therapy or medication, in the time between the end of the CBT program and follow-up.

ADHD Can Arise After Head Injuries

Secondary attention-deficit hyperactivity disorder was diagnosed in 15 of 103 children (15%) aged 5–14 years who were assessed 12 months after a traumatic head injury, said Jeffrey E. Max, M.B., of the University of California, San Diego, and his colleagues.

Secondary ADHD was significantly associated with several new-onset disorders, such as personality change, 6–12 months after the injury. Of 82 children who returned after 24 months, 17 (21%) were diagnosed with secondary ADHD, and many of the same new-onset conditions remained (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1041–9).

Children with lower preinjury adaptive function and greater preinjury psychosocial adversity were more likely to develop secondary ADHD. But the condition was not associated with age, sex, preinjury psychiatric disorder, or family psychiatric history.

Popular Ethnic Students Likely to Smoke

Popular nonwhite middle-school students were significantly more likely to smoke than were less popular peers, according to data from 1,486 sixth- and seventh-grade children in 16 southern California schools, said Thomas W. Valente, Ph.D., and his associates at the University of Southern California, Alhambra.

The ethnic makeup of the schools was primarily Hispanic and Asian; when classified as white or nonwhite, the association between popularity and smoking was significant among nonwhite children only. Popularity was associated with increased smoking by an adjusted odds ratio of 5.1 and with an increased susceptibility to smoking by an adjusted odds ratio of 5.6 (J. Adolesc. Health 2005;37:323–9). Popularity was assessed by asking students to name their closest friends and to name students who would be good leaders for a classroom project.

Bipolarity Affects Bowel Behavior

Encopresis and enuresis were more common in a cohort of 93 children and adolescents aged 7–16 years with early adolescent bipolar disorder I phenotype, compared with 81 children with ADHD and 94 healthy controls, wrote Tricia Klages and her colleagues at Washington University in St. Louis.

There were no significant differences in age, gender, or pubertal status among the groups. Encopresis (15% vs. 3%) and enuresis (22% vs. 6%) were significantly more common among prepubertal and early adolescent bipolar disorder I phenotype (PEA-BP) children compared with healthy controls. Although both conditions were more prevalent among PEA-BP children compared with ADHD children, the differences were not statistically significant (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1050–7). Maternal hostility appeared to be a significant factor; it was noted for 59% of subjects overall, and was significantly more common in children with encopresis than with nonencopretic children (92% vs. 56%).

Teen Opioid Treatments Compared

A combination of buprenorphine and behavioral intervention was significantly more effective than clonidine and behavioral intervention for the treatment of opioid dependence in adolescents, said Lisa A. Marsch, Ph.D.–who conducted the study while at the University of Vermont, Burlington–and her colleagues.

The randomized, double-blind, controlled study lasted for 28 days and included 36 adolescents aged 13–18 years who met the DSM-IV criteria for opioid dependence (Arch. Gen. Psychiatry 2005;62:1157–64). The flexible dosing procedure was based on weight and self-reported opioid use. Overall, significantly more adolescents in the buprenorphine group stayed in treatment (72%), compared with the clonidine group (39%). In addition, 61% of the buprenorphine group participated in the naltrexone phase of the study, which required three opioid-negative urine samples within a week, compared with 5% of the clonidine group.

CBT Benefits Endure for OCD Patients

Cognitive-behavioral therapy provided relief for children and adolescents with obsessive-compulsive disorder at 12–18 months' follow-up, said Paula Barrett, Ph.D., of Griffith University in Brisbane, Australia, and her associates. In a study of 48 participants aged 8–19 years, 70% of those in individual therapy and 84% of those in group therapy were free of OCD diagnosis at 12 months (J. Am. Acad. Child. Adolesc. Psychiatry 2005;44:1005–14). There were no significant changes in these numbers at 18 months, which suggests that children who were diagnosis free at the end of the treatment period tended to remain healthy.

Most of the patients (83%) received no additional treatment, including therapy or medication, in the time between the end of the CBT program and follow-up.

HOUSTON – The atypical antipsychotic aripiprazole reduced symptoms such as aggression, hyperactivity, and impulsivity in 56% of 32 children with developmental disabilities, according to Maria R. Valicenti-McDermott, M.D., and Howard Demb, M.D..

Previous studies have shown that aripiprazole (Abilify) has fewer side effects, compared with most other typical and atypical antipsychotics. In their retrospective study, the investigators assessed clinical efficacy and side effects of the drug when it was used to treat emotional and behavioral problems in children with developmental disorders, they wrote in a poster presented at the annual meeting of the American Society of Adolescent Psychiatry.

The study included the first 32 children, aged 5–19 years, treated with aripiprazole at an urban clinic for children with developmental disorders, wrote Dr. Valicenti-McDermott and Dr. Demb of the Albert Einstein College of Medicine, New York.

All but 1 child had multiple diagnoses: 18 had mental retardation, 16 had autistic disorder, and 12 had attention-deficit hyperactivity disorder. Other diagnoses included mood disorder, multiple complex developmental disorder, disruptive behavior disorder, oppositional defiant disorder, pervasive developmental disorders, reactive attachment disorder, sleep disorders, and bipolar disorder.

The initial mean daily dosage of aripiprazole was 7.1 mg (0.17 mg/kg per day). The children reported for monthly visits and had used aripiprazole for at least 6 months at the time of the study. The mean maintenance dosage was 10.55 mg (0.27 mg/kg per day).

Overall, the medication was effective in improving symptoms or maintaining improvement in 10 of the 18 children with mental retardation (56%). Improvement in symptoms occurred in 9 of the 12 children with attention-deficit hyperactivity disorder (75%), 5 of the 6 children with disruptive behavior disorder (83%), and 7 of the 19 children with pervasive developmental disorders (37%). Among children with pervasive developmental disorders, drug effectiveness was higher in those with mental retardation (38%) than in those without mental retardation (33%).

The presence of an autism spectrum disorder, however, predicted a worse outcome. In theory, higher dosages might be more effective in children with autism, Dr. Demb said in an interview.

Although more than half the children showed improvement in their side effect profiles, weight gain occurred in all the children during the course of the study, and three discontinued the medication because of weight gain. The mean body mass index increased from 22.5 to 24.1 kg/m2 during the follow-up period.

HOUSTON – The atypical antipsychotic aripiprazole reduced symptoms such as aggression, hyperactivity, and impulsivity in 56% of 32 children with developmental disabilities, according to Maria R. Valicenti-McDermott, M.D., and Howard Demb, M.D..

Previous studies have shown that aripiprazole (Abilify) has fewer side effects, compared with most other typical and atypical antipsychotics. In their retrospective study, the investigators assessed clinical efficacy and side effects of the drug when it was used to treat emotional and behavioral problems in children with developmental disorders, they wrote in a poster presented at the annual meeting of the American Society of Adolescent Psychiatry.

The study included the first 32 children, aged 5–19 years, treated with aripiprazole at an urban clinic for children with developmental disorders, wrote Dr. Valicenti-McDermott and Dr. Demb of the Albert Einstein College of Medicine, New York.

All but 1 child had multiple diagnoses: 18 had mental retardation, 16 had autistic disorder, and 12 had attention-deficit hyperactivity disorder. Other diagnoses included mood disorder, multiple complex developmental disorder, disruptive behavior disorder, oppositional defiant disorder, pervasive developmental disorders, reactive attachment disorder, sleep disorders, and bipolar disorder.

The initial mean daily dosage of aripiprazole was 7.1 mg (0.17 mg/kg per day). The children reported for monthly visits and had used aripiprazole for at least 6 months at the time of the study. The mean maintenance dosage was 10.55 mg (0.27 mg/kg per day).

Overall, the medication was effective in improving symptoms or maintaining improvement in 10 of the 18 children with mental retardation (56%). Improvement in symptoms occurred in 9 of the 12 children with attention-deficit hyperactivity disorder (75%), 5 of the 6 children with disruptive behavior disorder (83%), and 7 of the 19 children with pervasive developmental disorders (37%). Among children with pervasive developmental disorders, drug effectiveness was higher in those with mental retardation (38%) than in those without mental retardation (33%).

The presence of an autism spectrum disorder, however, predicted a worse outcome. In theory, higher dosages might be more effective in children with autism, Dr. Demb said in an interview.

Although more than half the children showed improvement in their side effect profiles, weight gain occurred in all the children during the course of the study, and three discontinued the medication because of weight gain. The mean body mass index increased from 22.5 to 24.1 kg/m2 during the follow-up period.

HOUSTON – The atypical antipsychotic aripiprazole reduced symptoms such as aggression, hyperactivity, and impulsivity in 56% of 32 children with developmental disabilities, according to Maria R. Valicenti-McDermott, M.D., and Howard Demb, M.D..

Previous studies have shown that aripiprazole (Abilify) has fewer side effects, compared with most other typical and atypical antipsychotics. In their retrospective study, the investigators assessed clinical efficacy and side effects of the drug when it was used to treat emotional and behavioral problems in children with developmental disorders, they wrote in a poster presented at the annual meeting of the American Society of Adolescent Psychiatry.

The study included the first 32 children, aged 5–19 years, treated with aripiprazole at an urban clinic for children with developmental disorders, wrote Dr. Valicenti-McDermott and Dr. Demb of the Albert Einstein College of Medicine, New York.

All but 1 child had multiple diagnoses: 18 had mental retardation, 16 had autistic disorder, and 12 had attention-deficit hyperactivity disorder. Other diagnoses included mood disorder, multiple complex developmental disorder, disruptive behavior disorder, oppositional defiant disorder, pervasive developmental disorders, reactive attachment disorder, sleep disorders, and bipolar disorder.

The initial mean daily dosage of aripiprazole was 7.1 mg (0.17 mg/kg per day). The children reported for monthly visits and had used aripiprazole for at least 6 months at the time of the study. The mean maintenance dosage was 10.55 mg (0.27 mg/kg per day).

Overall, the medication was effective in improving symptoms or maintaining improvement in 10 of the 18 children with mental retardation (56%). Improvement in symptoms occurred in 9 of the 12 children with attention-deficit hyperactivity disorder (75%), 5 of the 6 children with disruptive behavior disorder (83%), and 7 of the 19 children with pervasive developmental disorders (37%). Among children with pervasive developmental disorders, drug effectiveness was higher in those with mental retardation (38%) than in those without mental retardation (33%).

The presence of an autism spectrum disorder, however, predicted a worse outcome. In theory, higher dosages might be more effective in children with autism, Dr. Demb said in an interview.

Although more than half the children showed improvement in their side effect profiles, weight gain occurred in all the children during the course of the study, and three discontinued the medication because of weight gain. The mean body mass index increased from 22.5 to 24.1 kg/m2 during the follow-up period.

Children who receive cognitive stimulation and emotional support from their parents when they are 4 years old are less likely to become bullies, but early television watching promotes bullying, reported Frederick J. Zimmerman, Ph.D., and his colleagues at the University of Washington, Seattle.

The results lend support to theories that bullying tendencies arise from cognitive as well as emotional problems. In a multivariate logistic regression analysis, the investigators reviewed data from the National Longitudinal Survey of Youth 1979 Children and Young Adults on 1,266 children aged 6–11 years (Arch. Pediatr. Adolesc. Med. 2005;159:384–8).

A single standard-deviation increase in each of the emotional support and cognitive stimulation scores at age 4 years was associated with a 33% decrease in the odds of becoming a bully in elementary school (odds ratio 0.67). The investigators reported that a standard-deviation “increase in the number of hours of television watched at age 4 years was associated with an approximate 25% increase in the probability of being described as a bully by the child's mother at ages 6 through 11 years.” The odds ratio for each hour of television watched per day was 1.06.

About 49% of the children were female, and about 80% were white. Only one significant difference appeared after controlling for parental education and income, and the age, sex, and race of the child: Being of African American ethnicity was associated with decreased bullying.

The study was limited by its use of maternal reports and the absence of a standard definition for the term bully, Dr. Zimmerman and his associates commented.

“Maximizing cognitive stimulation and limiting television watching in the early years of development might reduce children's subsequent risk of becoming bullies,” the investigators noted.

Children who receive cognitive stimulation and emotional support from their parents when they are 4 years old are less likely to become bullies, but early television watching promotes bullying, reported Frederick J. Zimmerman, Ph.D., and his colleagues at the University of Washington, Seattle.

The results lend support to theories that bullying tendencies arise from cognitive as well as emotional problems. In a multivariate logistic regression analysis, the investigators reviewed data from the National Longitudinal Survey of Youth 1979 Children and Young Adults on 1,266 children aged 6–11 years (Arch. Pediatr. Adolesc. Med. 2005;159:384–8).

A single standard-deviation increase in each of the emotional support and cognitive stimulation scores at age 4 years was associated with a 33% decrease in the odds of becoming a bully in elementary school (odds ratio 0.67). The investigators reported that a standard-deviation “increase in the number of hours of television watched at age 4 years was associated with an approximate 25% increase in the probability of being described as a bully by the child's mother at ages 6 through 11 years.” The odds ratio for each hour of television watched per day was 1.06.

About 49% of the children were female, and about 80% were white. Only one significant difference appeared after controlling for parental education and income, and the age, sex, and race of the child: Being of African American ethnicity was associated with decreased bullying.

The study was limited by its use of maternal reports and the absence of a standard definition for the term bully, Dr. Zimmerman and his associates commented.

“Maximizing cognitive stimulation and limiting television watching in the early years of development might reduce children's subsequent risk of becoming bullies,” the investigators noted.

Children who receive cognitive stimulation and emotional support from their parents when they are 4 years old are less likely to become bullies, but early television watching promotes bullying, reported Frederick J. Zimmerman, Ph.D., and his colleagues at the University of Washington, Seattle.

The results lend support to theories that bullying tendencies arise from cognitive as well as emotional problems. In a multivariate logistic regression analysis, the investigators reviewed data from the National Longitudinal Survey of Youth 1979 Children and Young Adults on 1,266 children aged 6–11 years (Arch. Pediatr. Adolesc. Med. 2005;159:384–8).

A single standard-deviation increase in each of the emotional support and cognitive stimulation scores at age 4 years was associated with a 33% decrease in the odds of becoming a bully in elementary school (odds ratio 0.67). The investigators reported that a standard-deviation “increase in the number of hours of television watched at age 4 years was associated with an approximate 25% increase in the probability of being described as a bully by the child's mother at ages 6 through 11 years.” The odds ratio for each hour of television watched per day was 1.06.

About 49% of the children were female, and about 80% were white. Only one significant difference appeared after controlling for parental education and income, and the age, sex, and race of the child: Being of African American ethnicity was associated with decreased bullying.

The study was limited by its use of maternal reports and the absence of a standard definition for the term bully, Dr. Zimmerman and his associates commented.

“Maximizing cognitive stimulation and limiting television watching in the early years of development might reduce children's subsequent risk of becoming bullies,” the investigators noted.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues.

Regular use of noninvasive indices to assess ulcerative colitis could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), which involved endoscopy, and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index, which involved short symptom surveys and blood tests. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate ulcerative colitis patients, he said.

One explanation for endoscopy's minor role might be that other items on the same scale have measured the same predictive factors, such as patient-reported stool frequency and the frequency and amount of blood in the stool, which would make endoscopy redundant, he explained.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said.

The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope. “If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

“The best arbiter of remission is the patient,” he added, inasmuch as the patient will choose whether to seek additional health care.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues.

Regular use of noninvasive indices to assess ulcerative colitis could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), which involved endoscopy, and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index, which involved short symptom surveys and blood tests. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate ulcerative colitis patients, he said.

One explanation for endoscopy's minor role might be that other items on the same scale have measured the same predictive factors, such as patient-reported stool frequency and the frequency and amount of blood in the stool, which would make endoscopy redundant, he explained.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said.

The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope. “If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

“The best arbiter of remission is the patient,” he added, inasmuch as the patient will choose whether to seek additional health care.

WASHINGTON — Endoscopy is an invasive procedure that patients don't like, and it may not be necessary for the evaluation of ulcerative colitis, Peter Higgins, M.D., said at the Clinical Research 2005 meeting.

In a study of 66 consecutive adult ulcerative colitis patients, results from two noninvasive indices overlapped significantly with results from invasive indices, said Dr. Higgins of the University of Michigan, Ann Arbor, and his colleagues.

Regular use of noninvasive indices to assess ulcerative colitis could lower costs and encourage more patients to participate in clinical trials, he noted.

The investigators compared invasive and noninvasive indices in terms of how well each measured disease remission and other clinically important outcomes. The invasive indices used were the St. Mark's Index and the Ulcerative Colitis Disease Activity Index (UCDAI), which involved endoscopy, and the noninvasive indices were the Simple Clinical Colitis Activity Index (SCCAI) and the Seo index, which involved short symptom surveys and blood tests. In addition, the doctors simply asked patients whether their disease was in remission.

Other indices are available in addition to those used in this study, Dr. Higgins said. “The problem is that none of them are validated, and none of them work that well.”

The investigators measured the correlations between the various indices to determine whether the noninvasive tests could provide similar information to that provided by the invasive tests. The two noninvasive indices, SCCAI and Seo, correlated well with the invasive St. Mark's index, with correlations of 0.86 for the SCCAI and 0.70 for Seo.

When the two invasive indices were compared with each other, the UCDAI endoscopy item predicted only 0.04% of the variance in the St. Mark's index after adjustment for the three noninvasive items on the UCDAI index.

Overall, endoscopy contributed little to the assessment—significantly less than the 10% that Dr. Higgins expected. “We may not need endoscopy” to evaluate ulcerative colitis patients, he said.

One explanation for endoscopy's minor role might be that other items on the same scale have measured the same predictive factors, such as patient-reported stool frequency and the frequency and amount of blood in the stool, which would make endoscopy redundant, he explained.

Dr. Higgins concluded that noninvasive indices could effectively predict remission. “We're not losing much by leaving out endoscopy,” he said.

The clinical practice of treating patients based on their reported symptoms is appropriate, and clinicians are correct to avoid rushing to scope. “If the patient tells you they have 10 bloody stools, they are having a flare,” he said at the meeting, sponsored by the American Federation for Medical Research.

“The best arbiter of remission is the patient,” he added, inasmuch as the patient will choose whether to seek additional health care.

CHICAGO — Nonsurgical patients reported greater pain than did surgical patients during dressing changes and when having two or more treatment procedures, said Nancy Stotts, R.N., Ed.D., at the annual meeting of the Wound Healing Society.

She and her colleagues conducted a study of pain in 412 hospitalized adults at multiple locations, 74% of whom were surgical patients. Most of the patients were male (53%) and white (74%), and had chest wounds (60%). The average wound was 11.8 cm long and 2.5 cm deep.

Of the 412 patients, 93 (23%) were premedicated, and 19 (5%) received pain medications during wound care. Only 7.3% of the surgical patients and 5.9% of the nonsurgical patients received analgesics after their dressings were changed, noted Dr. Stotts, a professor of physiological nursing at the University of California, San Francisco.

Opioids were the most common medications, and the mean dose was 6.8 mg for surgical and nonsurgical patients alike. Sedatives and NSAIDs were rarely used in this patient population, Dr. Stotts said.

The patients' subjective experience of pain was measured using a numeric rating scale (NRS), on which 0 equals no pain and 10 equals the worst possible pain. Patients' pain scores were measured before, immediately after, and 10 minutes after the wound care procedures, which included dressing change, debridement, packing, and irrigation.

Overall, the patients reported the most intense pain during a wound care procedure, when the average NRS score was 4.4.

Nonsurgical patients reported significantly greater pain than did surgical patients, with average NRS scores of 5.3 and 4.1, respectively.

The higher pain scores in the nonsurgical patients were associated only with dressing changes and with undergoing two or more wound care procedures.

“Pain intensity did not differ with age, sex, or race,” Dr. Stotts observed.

When patients were given a choice of words that described their pain, the word “stinging” was often used to describe debridement; “stabbing” and “sharp” were often used to describe pain associated with any wound care procedure.

In addition to pain medications, patients and nurses used techniques such as humor, distraction, and deep breathing to manage pain during wound care procedures.

Pain seems to be undertreated in the hospitalized population, although it may be managed more effectively in surgical patients, Dr. Stotts said.

Further research on the effect of pain on wound-related patient outcomes could help develop pain management strategies, she added, pointing out that current data are limited.

CHICAGO — Nonsurgical patients reported greater pain than did surgical patients during dressing changes and when having two or more treatment procedures, said Nancy Stotts, R.N., Ed.D., at the annual meeting of the Wound Healing Society.

She and her colleagues conducted a study of pain in 412 hospitalized adults at multiple locations, 74% of whom were surgical patients. Most of the patients were male (53%) and white (74%), and had chest wounds (60%). The average wound was 11.8 cm long and 2.5 cm deep.

Of the 412 patients, 93 (23%) were premedicated, and 19 (5%) received pain medications during wound care. Only 7.3% of the surgical patients and 5.9% of the nonsurgical patients received analgesics after their dressings were changed, noted Dr. Stotts, a professor of physiological nursing at the University of California, San Francisco.

Opioids were the most common medications, and the mean dose was 6.8 mg for surgical and nonsurgical patients alike. Sedatives and NSAIDs were rarely used in this patient population, Dr. Stotts said.

The patients' subjective experience of pain was measured using a numeric rating scale (NRS), on which 0 equals no pain and 10 equals the worst possible pain. Patients' pain scores were measured before, immediately after, and 10 minutes after the wound care procedures, which included dressing change, debridement, packing, and irrigation.

Overall, the patients reported the most intense pain during a wound care procedure, when the average NRS score was 4.4.

Nonsurgical patients reported significantly greater pain than did surgical patients, with average NRS scores of 5.3 and 4.1, respectively.

The higher pain scores in the nonsurgical patients were associated only with dressing changes and with undergoing two or more wound care procedures.

“Pain intensity did not differ with age, sex, or race,” Dr. Stotts observed.

When patients were given a choice of words that described their pain, the word “stinging” was often used to describe debridement; “stabbing” and “sharp” were often used to describe pain associated with any wound care procedure.

In addition to pain medications, patients and nurses used techniques such as humor, distraction, and deep breathing to manage pain during wound care procedures.

Pain seems to be undertreated in the hospitalized population, although it may be managed more effectively in surgical patients, Dr. Stotts said.

Further research on the effect of pain on wound-related patient outcomes could help develop pain management strategies, she added, pointing out that current data are limited.

CHICAGO — Nonsurgical patients reported greater pain than did surgical patients during dressing changes and when having two or more treatment procedures, said Nancy Stotts, R.N., Ed.D., at the annual meeting of the Wound Healing Society.

She and her colleagues conducted a study of pain in 412 hospitalized adults at multiple locations, 74% of whom were surgical patients. Most of the patients were male (53%) and white (74%), and had chest wounds (60%). The average wound was 11.8 cm long and 2.5 cm deep.

Of the 412 patients, 93 (23%) were premedicated, and 19 (5%) received pain medications during wound care. Only 7.3% of the surgical patients and 5.9% of the nonsurgical patients received analgesics after their dressings were changed, noted Dr. Stotts, a professor of physiological nursing at the University of California, San Francisco.

Opioids were the most common medications, and the mean dose was 6.8 mg for surgical and nonsurgical patients alike. Sedatives and NSAIDs were rarely used in this patient population, Dr. Stotts said.

The patients' subjective experience of pain was measured using a numeric rating scale (NRS), on which 0 equals no pain and 10 equals the worst possible pain. Patients' pain scores were measured before, immediately after, and 10 minutes after the wound care procedures, which included dressing change, debridement, packing, and irrigation.

Overall, the patients reported the most intense pain during a wound care procedure, when the average NRS score was 4.4.

Nonsurgical patients reported significantly greater pain than did surgical patients, with average NRS scores of 5.3 and 4.1, respectively.

The higher pain scores in the nonsurgical patients were associated only with dressing changes and with undergoing two or more wound care procedures.

“Pain intensity did not differ with age, sex, or race,” Dr. Stotts observed.

When patients were given a choice of words that described their pain, the word “stinging” was often used to describe debridement; “stabbing” and “sharp” were often used to describe pain associated with any wound care procedure.

In addition to pain medications, patients and nurses used techniques such as humor, distraction, and deep breathing to manage pain during wound care procedures.

Pain seems to be undertreated in the hospitalized population, although it may be managed more effectively in surgical patients, Dr. Stotts said.

Further research on the effect of pain on wound-related patient outcomes could help develop pain management strategies, she added, pointing out that current data are limited.

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 menin-gococcemia.

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 menin-gococcemia.

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 menin-gococcemia.

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.

Some tympanostomy tubes are going to go bad. The reasons include water precaution issues, otorrhea, blocked tubes, development of granulation tissue, and extrusion problems.

In the first place, the tubes serve as pressure equalizers in children with structural or functional eustachian tube dysfunction, according to Benjamin Cable, M.D., chief of pediatric otolaryngology at Tripler Army Medical Center in Honolulu.

Overall, children with tubes suffer an average of 1.5 episodes of otorrhea per year that the tubes are in place. Short- acting tubes remain in place for 6–18 months, with an average placement time of 13 months. Long-acting tubes remain in place for at least 17 months and sometimes indefinitely, so there is plenty of time for complications to develop, he said.

Despite the potential problems, consider tubes for children who experience bilateral effusion for 3 months or have three episodes of acute otitis media in 6 months or four episodes in 12 months, Dr. Cable said in an interview.

Stress the importance of being careful in the water, but ear plugs are not particularly helpful for two reasons, Dr. Cable said. First, the opening of an ear tube is so small that a drop of water would not penetrate due to surface tension. If children swim on the surface and do not dive well below the water, there is little chance of water penetrating the tubes. Second, ear plugs often do not create tight fits within the ear canal.

Otorrhea can occur due to nasopharyngeal pathogens or external auditory canal pathogens. Children who go without treatment of otorrhea tend to have prolonged drainage, Dr. Cable said.

First-line therapy should be ototopical drops in the ear canal, which have demonstrated effectiveness. Oral antibiotics are the second-line therapy, and in refractory cases, culture-directed therapy is key, Dr. Cable noted. Drops or oral therapy should be given for 7–10 days, but intravenous therapy may take up to 6 weeks and include home regimens.

Acute posttympanostomy otorrhea is common. However, despite the presence of elevated gastric enzymes in cases of middle ear effusion, gastric reflux has not been shown to play a significant role in acute posttympanostomy otorrhea. For example, measurable pepsinogen concentrations were below the normal reference ranges in a recent prospective study of 24 children aged 2–16 years (Otolaryngol. Head Neck Surg. 2005;132:523–6).

Tube removal is an option for severe cases of otorrhea. “Most often, tubes that require removal are ones that have become blocked with dried otorrhea or blood,” Dr. Cable said. If the debris cannot be loosened by drops or removed by physical cleaning, the tubes can be removed and replaced in a slightly different location.

Granulation tissue must be treated with steroid-containing medication. “New ototopical drops now often contain a combination antibiotic and steroid, Ciprodex, for instance,” Dr. Cable said. “If this is not available, steroid drops made for ophthalmic use can be used in the ear.”

Autoextrusion occurs in 95% of cases of short-acting tubes. Tubes that last longer than 2 years are considered “retained.” “The longer the tubes are in place, the less likely that the small perforation will heal after extrusion,” Dr. Cable explained. “We used to think that happened at 2 years, but the evidence is now pointing more solidly at longer than 3 years, and most surgeons will recommend removal somewhere between 2 and 3 years.”

Perforation closure occurs in approximately 97% of short-acting tubes and 80% of long-acting tubes, Dr. Cable said.

This tube is in the classic position, with dried otorrhea in its center.

This tube is totally blocked with pink, fleshy, shiny granulation tissue.

This eardrum perforation, or hole, did not heal after the tube extruded. Photos courtesy Dr. Benjamin Cable

Some tympanostomy tubes are going to go bad. The reasons include water precaution issues, otorrhea, blocked tubes, development of granulation tissue, and extrusion problems.

In the first place, the tubes serve as pressure equalizers in children with structural or functional eustachian tube dysfunction, according to Benjamin Cable, M.D., chief of pediatric otolaryngology at Tripler Army Medical Center in Honolulu.

Overall, children with tubes suffer an average of 1.5 episodes of otorrhea per year that the tubes are in place. Short- acting tubes remain in place for 6–18 months, with an average placement time of 13 months. Long-acting tubes remain in place for at least 17 months and sometimes indefinitely, so there is plenty of time for complications to develop, he said.

Despite the potential problems, consider tubes for children who experience bilateral effusion for 3 months or have three episodes of acute otitis media in 6 months or four episodes in 12 months, Dr. Cable said in an interview.

Stress the importance of being careful in the water, but ear plugs are not particularly helpful for two reasons, Dr. Cable said. First, the opening of an ear tube is so small that a drop of water would not penetrate due to surface tension. If children swim on the surface and do not dive well below the water, there is little chance of water penetrating the tubes. Second, ear plugs often do not create tight fits within the ear canal.

Otorrhea can occur due to nasopharyngeal pathogens or external auditory canal pathogens. Children who go without treatment of otorrhea tend to have prolonged drainage, Dr. Cable said.

First-line therapy should be ototopical drops in the ear canal, which have demonstrated effectiveness. Oral antibiotics are the second-line therapy, and in refractory cases, culture-directed therapy is key, Dr. Cable noted. Drops or oral therapy should be given for 7–10 days, but intravenous therapy may take up to 6 weeks and include home regimens.

Acute posttympanostomy otorrhea is common. However, despite the presence of elevated gastric enzymes in cases of middle ear effusion, gastric reflux has not been shown to play a significant role in acute posttympanostomy otorrhea. For example, measurable pepsinogen concentrations were below the normal reference ranges in a recent prospective study of 24 children aged 2–16 years (Otolaryngol. Head Neck Surg. 2005;132:523–6).

Tube removal is an option for severe cases of otorrhea. “Most often, tubes that require removal are ones that have become blocked with dried otorrhea or blood,” Dr. Cable said. If the debris cannot be loosened by drops or removed by physical cleaning, the tubes can be removed and replaced in a slightly different location.

Granulation tissue must be treated with steroid-containing medication. “New ototopical drops now often contain a combination antibiotic and steroid, Ciprodex, for instance,” Dr. Cable said. “If this is not available, steroid drops made for ophthalmic use can be used in the ear.”

Autoextrusion occurs in 95% of cases of short-acting tubes. Tubes that last longer than 2 years are considered “retained.” “The longer the tubes are in place, the less likely that the small perforation will heal after extrusion,” Dr. Cable explained. “We used to think that happened at 2 years, but the evidence is now pointing more solidly at longer than 3 years, and most surgeons will recommend removal somewhere between 2 and 3 years.”

Perforation closure occurs in approximately 97% of short-acting tubes and 80% of long-acting tubes, Dr. Cable said.

This tube is in the classic position, with dried otorrhea in its center.

This tube is totally blocked with pink, fleshy, shiny granulation tissue.

This eardrum perforation, or hole, did not heal after the tube extruded. Photos courtesy Dr. Benjamin Cable

Some tympanostomy tubes are going to go bad. The reasons include water precaution issues, otorrhea, blocked tubes, development of granulation tissue, and extrusion problems.

In the first place, the tubes serve as pressure equalizers in children with structural or functional eustachian tube dysfunction, according to Benjamin Cable, M.D., chief of pediatric otolaryngology at Tripler Army Medical Center in Honolulu.

Overall, children with tubes suffer an average of 1.5 episodes of otorrhea per year that the tubes are in place. Short- acting tubes remain in place for 6–18 months, with an average placement time of 13 months. Long-acting tubes remain in place for at least 17 months and sometimes indefinitely, so there is plenty of time for complications to develop, he said.

Despite the potential problems, consider tubes for children who experience bilateral effusion for 3 months or have three episodes of acute otitis media in 6 months or four episodes in 12 months, Dr. Cable said in an interview.

Stress the importance of being careful in the water, but ear plugs are not particularly helpful for two reasons, Dr. Cable said. First, the opening of an ear tube is so small that a drop of water would not penetrate due to surface tension. If children swim on the surface and do not dive well below the water, there is little chance of water penetrating the tubes. Second, ear plugs often do not create tight fits within the ear canal.

Otorrhea can occur due to nasopharyngeal pathogens or external auditory canal pathogens. Children who go without treatment of otorrhea tend to have prolonged drainage, Dr. Cable said.

First-line therapy should be ototopical drops in the ear canal, which have demonstrated effectiveness. Oral antibiotics are the second-line therapy, and in refractory cases, culture-directed therapy is key, Dr. Cable noted. Drops or oral therapy should be given for 7–10 days, but intravenous therapy may take up to 6 weeks and include home regimens.

Acute posttympanostomy otorrhea is common. However, despite the presence of elevated gastric enzymes in cases of middle ear effusion, gastric reflux has not been shown to play a significant role in acute posttympanostomy otorrhea. For example, measurable pepsinogen concentrations were below the normal reference ranges in a recent prospective study of 24 children aged 2–16 years (Otolaryngol. Head Neck Surg. 2005;132:523–6).

Tube removal is an option for severe cases of otorrhea. “Most often, tubes that require removal are ones that have become blocked with dried otorrhea or blood,” Dr. Cable said. If the debris cannot be loosened by drops or removed by physical cleaning, the tubes can be removed and replaced in a slightly different location.

Granulation tissue must be treated with steroid-containing medication. “New ototopical drops now often contain a combination antibiotic and steroid, Ciprodex, for instance,” Dr. Cable said. “If this is not available, steroid drops made for ophthalmic use can be used in the ear.”

Autoextrusion occurs in 95% of cases of short-acting tubes. Tubes that last longer than 2 years are considered “retained.” “The longer the tubes are in place, the less likely that the small perforation will heal after extrusion,” Dr. Cable explained. “We used to think that happened at 2 years, but the evidence is now pointing more solidly at longer than 3 years, and most surgeons will recommend removal somewhere between 2 and 3 years.”

Perforation closure occurs in approximately 97% of short-acting tubes and 80% of long-acting tubes, Dr. Cable said.

This tube is in the classic position, with dried otorrhea in its center.

This tube is totally blocked with pink, fleshy, shiny granulation tissue.

This eardrum perforation, or hole, did not heal after the tube extruded. Photos courtesy Dr. Benjamin Cable

Observing good hygiene practices and environmental modifications can reduce the risk of infection from lymphocytic choriomeningitis virus from rodents, both pet and wild, the Centers for Disease Control and Prevention has advised.

Lymphocytic choriomeningitis virus (LCMV) has been shown to transfer from rodents to humans, but not from person to person. Symptoms of LCMV are flulike, including stiff neck, fever, muscle aches, and nausea. (MMWR 2005;54:747–9).

Most LCMV infections do not cause serious illness, although pregnant women may be at an increased risk. Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to others. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. If possible, pregnant women should arrange for a friend or relative to adopt the rodent during their pregnancy.

Although the risk for LCMV is low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to the CDC.

The prevalence of LCVM in pet rodents is not known; it is found in hamsters, guinea pigs, and pet mice that have come into contact with infected wild rodents at pet stores, breeders, or homes.

Anyone who handles pet rodents should follow the care practices below to reduce their risk for infection:

▸ Wash hands with soap and water or a hand sanitizer after handling pet rodents or cleaning areas where they have been.

▸ Keep cages clean and change soiled bedding.

▸ Clean cages outside or in a well-ventilated area.

▸ Supervise young children while they clean cages or handle rodents and ensure that children wash their hands afterward.

▸ Never kiss rodents or hold them close to the face.

▸ Never allow pet rodents to come into contact with wild rodents, or wild rodent nests or droppings, and never release pet rodents into the wild.

▸ Keep rodent cages and food supplies covered.

▸ Always supervise pet rodents when they are not in their cages.

For additional information on how to purchase healthy pet rodents, and then keep them healthy, visit www.cdc.gov/healthypets/lcmv_rodents.htm

Observing good hygiene practices and environmental modifications can reduce the risk of infection from lymphocytic choriomeningitis virus from rodents, both pet and wild, the Centers for Disease Control and Prevention has advised.

Lymphocytic choriomeningitis virus (LCMV) has been shown to transfer from rodents to humans, but not from person to person. Symptoms of LCMV are flulike, including stiff neck, fever, muscle aches, and nausea. (MMWR 2005;54:747–9).

Most LCMV infections do not cause serious illness, although pregnant women may be at an increased risk. Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to others. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. If possible, pregnant women should arrange for a friend or relative to adopt the rodent during their pregnancy.

Although the risk for LCMV is low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to the CDC.

The prevalence of LCVM in pet rodents is not known; it is found in hamsters, guinea pigs, and pet mice that have come into contact with infected wild rodents at pet stores, breeders, or homes.

Anyone who handles pet rodents should follow the care practices below to reduce their risk for infection:

▸ Wash hands with soap and water or a hand sanitizer after handling pet rodents or cleaning areas where they have been.

▸ Keep cages clean and change soiled bedding.

▸ Clean cages outside or in a well-ventilated area.

▸ Supervise young children while they clean cages or handle rodents and ensure that children wash their hands afterward.

▸ Never kiss rodents or hold them close to the face.

▸ Never allow pet rodents to come into contact with wild rodents, or wild rodent nests or droppings, and never release pet rodents into the wild.

▸ Keep rodent cages and food supplies covered.

▸ Always supervise pet rodents when they are not in their cages.

For additional information on how to purchase healthy pet rodents, and then keep them healthy, visit www.cdc.gov/healthypets/lcmv_rodents.htm

Observing good hygiene practices and environmental modifications can reduce the risk of infection from lymphocytic choriomeningitis virus from rodents, both pet and wild, the Centers for Disease Control and Prevention has advised.

Lymphocytic choriomeningitis virus (LCMV) has been shown to transfer from rodents to humans, but not from person to person. Symptoms of LCMV are flulike, including stiff neck, fever, muscle aches, and nausea. (MMWR 2005;54:747–9).

Most LCMV infections do not cause serious illness, although pregnant women may be at an increased risk. Pregnant women who discover wild mice or other rodents in their homes should leave the capture and removal of the animals to others. They should also avoid spending long periods of time in the same room as a pet rodent and should not clean the cage or feed the animal. If possible, pregnant women should arrange for a friend or relative to adopt the rodent during their pregnancy.

Although the risk for LCMV is low, transmission of infection from mother to fetus has been reported, and infection during the first or second trimester can cause developmental problems in the fetus, according to the CDC.

The prevalence of LCVM in pet rodents is not known; it is found in hamsters, guinea pigs, and pet mice that have come into contact with infected wild rodents at pet stores, breeders, or homes.

Anyone who handles pet rodents should follow the care practices below to reduce their risk for infection:

▸ Wash hands with soap and water or a hand sanitizer after handling pet rodents or cleaning areas where they have been.

▸ Keep cages clean and change soiled bedding.

▸ Clean cages outside or in a well-ventilated area.

▸ Supervise young children while they clean cages or handle rodents and ensure that children wash their hands afterward.

▸ Never kiss rodents or hold them close to the face.

▸ Never allow pet rodents to come into contact with wild rodents, or wild rodent nests or droppings, and never release pet rodents into the wild.

▸ Keep rodent cages and food supplies covered.

▸ Always supervise pet rodents when they are not in their cages.

For additional information on how to purchase healthy pet rodents, and then keep them healthy, visit www.cdc.gov/healthypets/lcmv_rodents.htm

MIAMI — Surgical site infections were significantly more likely among women who harbored Staphylococcus aureus prior to undergoing breast cancer surgery, according to data from 615 patients, A. Krishna, M.D., said at the joint annual meeting of the Surgical Infection Society and the Surgical Infection Society-Europe.

In a multicenter, prospective study conducted by Dr. Krishna and his colleagues at South Glasgow (Scotland) University Hospital, 83 of the 615 women (14%) carried S. aureus, as determined by preoperative nasal, axillary, and perineal swabs.

The patients were evaluated for surgical site infections for 30 days after their surgery. Within 30 days, infections occurred in 22 of the 83 women with S. aureus, compared with 75 of 532 women without S. aureus (27% vs. 14%).

Approximately 1 in 4 patients with S. aureus is likely to develop a postoperative wound infection, and the infection rate reported in this study falls within the range of rates reported in previous studies, Dr. Krishna noted.

The women enrolled in the study were undergoing primary surgery for breast cancer and were part of a larger randomized, controlled study of prophylactic antibiotic use.

MIAMI — Surgical site infections were significantly more likely among women who harbored Staphylococcus aureus prior to undergoing breast cancer surgery, according to data from 615 patients, A. Krishna, M.D., said at the joint annual meeting of the Surgical Infection Society and the Surgical Infection Society-Europe.

In a multicenter, prospective study conducted by Dr. Krishna and his colleagues at South Glasgow (Scotland) University Hospital, 83 of the 615 women (14%) carried S. aureus, as determined by preoperative nasal, axillary, and perineal swabs.

The patients were evaluated for surgical site infections for 30 days after their surgery. Within 30 days, infections occurred in 22 of the 83 women with S. aureus, compared with 75 of 532 women without S. aureus (27% vs. 14%).

Approximately 1 in 4 patients with S. aureus is likely to develop a postoperative wound infection, and the infection rate reported in this study falls within the range of rates reported in previous studies, Dr. Krishna noted.

The women enrolled in the study were undergoing primary surgery for breast cancer and were part of a larger randomized, controlled study of prophylactic antibiotic use.

MIAMI — Surgical site infections were significantly more likely among women who harbored Staphylococcus aureus prior to undergoing breast cancer surgery, according to data from 615 patients, A. Krishna, M.D., said at the joint annual meeting of the Surgical Infection Society and the Surgical Infection Society-Europe.

In a multicenter, prospective study conducted by Dr. Krishna and his colleagues at South Glasgow (Scotland) University Hospital, 83 of the 615 women (14%) carried S. aureus, as determined by preoperative nasal, axillary, and perineal swabs.

The patients were evaluated for surgical site infections for 30 days after their surgery. Within 30 days, infections occurred in 22 of the 83 women with S. aureus, compared with 75 of 532 women without S. aureus (27% vs. 14%).

Approximately 1 in 4 patients with S. aureus is likely to develop a postoperative wound infection, and the infection rate reported in this study falls within the range of rates reported in previous studies, Dr. Krishna noted.

The women enrolled in the study were undergoing primary surgery for breast cancer and were part of a larger randomized, controlled study of prophylactic antibiotic use.