Sharon Worcester

WASHINGTON – The choice of antiepileptic drugs for the treatment of pediatric convulsive status epilepticus was highly variable, and treatment timing and escalation were less than ideal in a pediatric Status Epilepticus Research Group study.

The findings suggest there is "room for improvement" in the management of this serious, life-threatening condition through more timely administration of antiepileptic drugs (AEDs) and through quicker progression from one AED to the next, Dr. Tobias Loddenkemper reported at the annual meeting of the American Epilepsy Society.

The findings represent a first step in addressing the inadequacies in the care of children with refractory convulsive status epilepticus (RCSE), and they underscore the need for parental education and ensuring that rescue medications are available for children with an epilepsy diagnosis, as well as the need for improved management in the inpatient setting, said Dr. Loddenkemper of Boston Children’s Hospital.

The analysis of RCSE episodes in 81 children aged 1 month to 21 years (mean age, 2.5 years) who were treated in the intensive care unit at any of the 11 U.S. tertiary referral hospitals that comprise the pediatric Status Epilepticus Research Group (pSERG) network showed that most episodes (79%) had onset out of the hospital. The median time to emergency medical services arrival was 15 minutes, and the median time to hospital arrival was 47 minutes. The median times to various steps of treatment far exceeded current guideline recommendations, according to Dr. Loddenkemper:

• 30 minutes for the administration of a first benzodiazepine drug by intravenous bolus dosing; guidelines call for treatment within 5 minutes.

• 69 minutes for the administration of a second drug; guidelines recommend 5-10 minutes.

• 120 minutes for the administration of a second non-benzodiazepine drug; guidelines call for 20-30 minutes.

• 180 minutes for the continuous infusion of anesthetic drugs; guidelines call for continuous infusion to begin within 30-70 minutes.

However, delays also occurred for in-hospital RCSE episodes, he said. The median times to first and second drugs for in-hospital episodes were 10 and 20 minutes, respectively.

Of the 81 patients included in the analysis, 75% were intubated and only 67% returned to baseline functioning after the RCSE episode. Four patients (4.9%) died.

"This [mortality] signifies how important this is," he said of RCSE during a press briefing at the meeting, noting that it is the most severe form of epilepsy, and that prompt and appropriate treatment is important for improving outcomes.

Of particular concern was the finding that most of the children in this study had a preexisting diagnosis of epilepsy, yet only half received a rescue medication in the outpatient setting.

"Technically, they should have had some kind of rescue medications, but they either were not given or were not prescribed," he said.

As for drug selection in this study, the most frequent choice of first benzodiazepine was lorazepam in 56% of cases, followed by diazepam in about a third of patients, and midazolam and clobazam in just a few cases each. The choice for a second benzodiazepine was most often lorazepam in 70% of cases, followed by midazolam and diazepam.

The choice of a first non-benzodiazepine drug was fosphenytoin in 52% of cases, followed by phenytoin and levetiracetam, Dr. Loddenkemper said. Phenobarbital, valproate, rufinamide, and propofol were also among the choices for first non-benzodiazepine drug. The choice of a second non-benzodiazepine drug was phenobarbital in 45% of cases, followed by levetiracetam, fosphenytoin, valproate, phenytoin, and propofol. The choice of anesthetic drug for continuous drug infusion was midazolam in 75% of cases. Other drugs used for continuous infusion included pentobarbital, propofol, and isoflurane. Pentobarbital was the first choice for second drug for infusion in 38% of cases.

The first choice of drug in each of those stages of treatment was generally within guidelines, but the high variability with respect to drug choices is concerning, he said.

All consecutive children presenting with RCSE to the ICUs in the pSERG network were included as long as they either failed at least two AEDs or required continuous infusion of an AED drug to abort their seizures.

Quicker progression from one drug to another in RCSE cases and coadministration of the first and second drugs are among strategies for improving outcomes. "Maybe we just have to treat faster," he suggested.

He also suggested that care could be improved by the use of dedicated treatment algorithms and dedicated teams of physicians who take care of patients with RCSE – much like the successful model for stroke care used at many hospitals in the United States.

Additional analysis from this study could shed more light on methods for improving outcomes. Data from an additional 46 patients are currently being analyzed, Dr. Loddenkemper said.

This study was funded by the American Epilepsy Society Infrastructure Award and the Epilepsy Foundation of America. Dr. Loddenkemper reported receiving research funding from Eisai and Lundbeck.

WASHINGTON – The choice of antiepileptic drugs for the treatment of pediatric convulsive status epilepticus was highly variable, and treatment timing and escalation were less than ideal in a pediatric Status Epilepticus Research Group study.

The findings suggest there is "room for improvement" in the management of this serious, life-threatening condition through more timely administration of antiepileptic drugs (AEDs) and through quicker progression from one AED to the next, Dr. Tobias Loddenkemper reported at the annual meeting of the American Epilepsy Society.

The findings represent a first step in addressing the inadequacies in the care of children with refractory convulsive status epilepticus (RCSE), and they underscore the need for parental education and ensuring that rescue medications are available for children with an epilepsy diagnosis, as well as the need for improved management in the inpatient setting, said Dr. Loddenkemper of Boston Children’s Hospital.

The analysis of RCSE episodes in 81 children aged 1 month to 21 years (mean age, 2.5 years) who were treated in the intensive care unit at any of the 11 U.S. tertiary referral hospitals that comprise the pediatric Status Epilepticus Research Group (pSERG) network showed that most episodes (79%) had onset out of the hospital. The median time to emergency medical services arrival was 15 minutes, and the median time to hospital arrival was 47 minutes. The median times to various steps of treatment far exceeded current guideline recommendations, according to Dr. Loddenkemper:

• 30 minutes for the administration of a first benzodiazepine drug by intravenous bolus dosing; guidelines call for treatment within 5 minutes.

• 69 minutes for the administration of a second drug; guidelines recommend 5-10 minutes.

• 120 minutes for the administration of a second non-benzodiazepine drug; guidelines call for 20-30 minutes.

• 180 minutes for the continuous infusion of anesthetic drugs; guidelines call for continuous infusion to begin within 30-70 minutes.

However, delays also occurred for in-hospital RCSE episodes, he said. The median times to first and second drugs for in-hospital episodes were 10 and 20 minutes, respectively.

Of the 81 patients included in the analysis, 75% were intubated and only 67% returned to baseline functioning after the RCSE episode. Four patients (4.9%) died.

"This [mortality] signifies how important this is," he said of RCSE during a press briefing at the meeting, noting that it is the most severe form of epilepsy, and that prompt and appropriate treatment is important for improving outcomes.

Of particular concern was the finding that most of the children in this study had a preexisting diagnosis of epilepsy, yet only half received a rescue medication in the outpatient setting.

"Technically, they should have had some kind of rescue medications, but they either were not given or were not prescribed," he said.

As for drug selection in this study, the most frequent choice of first benzodiazepine was lorazepam in 56% of cases, followed by diazepam in about a third of patients, and midazolam and clobazam in just a few cases each. The choice for a second benzodiazepine was most often lorazepam in 70% of cases, followed by midazolam and diazepam.

The choice of a first non-benzodiazepine drug was fosphenytoin in 52% of cases, followed by phenytoin and levetiracetam, Dr. Loddenkemper said. Phenobarbital, valproate, rufinamide, and propofol were also among the choices for first non-benzodiazepine drug. The choice of a second non-benzodiazepine drug was phenobarbital in 45% of cases, followed by levetiracetam, fosphenytoin, valproate, phenytoin, and propofol. The choice of anesthetic drug for continuous drug infusion was midazolam in 75% of cases. Other drugs used for continuous infusion included pentobarbital, propofol, and isoflurane. Pentobarbital was the first choice for second drug for infusion in 38% of cases.

The first choice of drug in each of those stages of treatment was generally within guidelines, but the high variability with respect to drug choices is concerning, he said.

All consecutive children presenting with RCSE to the ICUs in the pSERG network were included as long as they either failed at least two AEDs or required continuous infusion of an AED drug to abort their seizures.

Quicker progression from one drug to another in RCSE cases and coadministration of the first and second drugs are among strategies for improving outcomes. "Maybe we just have to treat faster," he suggested.

He also suggested that care could be improved by the use of dedicated treatment algorithms and dedicated teams of physicians who take care of patients with RCSE – much like the successful model for stroke care used at many hospitals in the United States.

Additional analysis from this study could shed more light on methods for improving outcomes. Data from an additional 46 patients are currently being analyzed, Dr. Loddenkemper said.

This study was funded by the American Epilepsy Society Infrastructure Award and the Epilepsy Foundation of America. Dr. Loddenkemper reported receiving research funding from Eisai and Lundbeck.

WASHINGTON – The choice of antiepileptic drugs for the treatment of pediatric convulsive status epilepticus was highly variable, and treatment timing and escalation were less than ideal in a pediatric Status Epilepticus Research Group study.

The findings suggest there is "room for improvement" in the management of this serious, life-threatening condition through more timely administration of antiepileptic drugs (AEDs) and through quicker progression from one AED to the next, Dr. Tobias Loddenkemper reported at the annual meeting of the American Epilepsy Society.

The findings represent a first step in addressing the inadequacies in the care of children with refractory convulsive status epilepticus (RCSE), and they underscore the need for parental education and ensuring that rescue medications are available for children with an epilepsy diagnosis, as well as the need for improved management in the inpatient setting, said Dr. Loddenkemper of Boston Children’s Hospital.

The analysis of RCSE episodes in 81 children aged 1 month to 21 years (mean age, 2.5 years) who were treated in the intensive care unit at any of the 11 U.S. tertiary referral hospitals that comprise the pediatric Status Epilepticus Research Group (pSERG) network showed that most episodes (79%) had onset out of the hospital. The median time to emergency medical services arrival was 15 minutes, and the median time to hospital arrival was 47 minutes. The median times to various steps of treatment far exceeded current guideline recommendations, according to Dr. Loddenkemper:

• 30 minutes for the administration of a first benzodiazepine drug by intravenous bolus dosing; guidelines call for treatment within 5 minutes.

• 69 minutes for the administration of a second drug; guidelines recommend 5-10 minutes.

• 120 minutes for the administration of a second non-benzodiazepine drug; guidelines call for 20-30 minutes.

• 180 minutes for the continuous infusion of anesthetic drugs; guidelines call for continuous infusion to begin within 30-70 minutes.

However, delays also occurred for in-hospital RCSE episodes, he said. The median times to first and second drugs for in-hospital episodes were 10 and 20 minutes, respectively.

Of the 81 patients included in the analysis, 75% were intubated and only 67% returned to baseline functioning after the RCSE episode. Four patients (4.9%) died.

"This [mortality] signifies how important this is," he said of RCSE during a press briefing at the meeting, noting that it is the most severe form of epilepsy, and that prompt and appropriate treatment is important for improving outcomes.

Of particular concern was the finding that most of the children in this study had a preexisting diagnosis of epilepsy, yet only half received a rescue medication in the outpatient setting.

"Technically, they should have had some kind of rescue medications, but they either were not given or were not prescribed," he said.

As for drug selection in this study, the most frequent choice of first benzodiazepine was lorazepam in 56% of cases, followed by diazepam in about a third of patients, and midazolam and clobazam in just a few cases each. The choice for a second benzodiazepine was most often lorazepam in 70% of cases, followed by midazolam and diazepam.

The choice of a first non-benzodiazepine drug was fosphenytoin in 52% of cases, followed by phenytoin and levetiracetam, Dr. Loddenkemper said. Phenobarbital, valproate, rufinamide, and propofol were also among the choices for first non-benzodiazepine drug. The choice of a second non-benzodiazepine drug was phenobarbital in 45% of cases, followed by levetiracetam, fosphenytoin, valproate, phenytoin, and propofol. The choice of anesthetic drug for continuous drug infusion was midazolam in 75% of cases. Other drugs used for continuous infusion included pentobarbital, propofol, and isoflurane. Pentobarbital was the first choice for second drug for infusion in 38% of cases.

The first choice of drug in each of those stages of treatment was generally within guidelines, but the high variability with respect to drug choices is concerning, he said.

All consecutive children presenting with RCSE to the ICUs in the pSERG network were included as long as they either failed at least two AEDs or required continuous infusion of an AED drug to abort their seizures.

Quicker progression from one drug to another in RCSE cases and coadministration of the first and second drugs are among strategies for improving outcomes. "Maybe we just have to treat faster," he suggested.

He also suggested that care could be improved by the use of dedicated treatment algorithms and dedicated teams of physicians who take care of patients with RCSE – much like the successful model for stroke care used at many hospitals in the United States.

Additional analysis from this study could shed more light on methods for improving outcomes. Data from an additional 46 patients are currently being analyzed, Dr. Loddenkemper said.

This study was funded by the American Epilepsy Society Infrastructure Award and the Epilepsy Foundation of America. Dr. Loddenkemper reported receiving research funding from Eisai and Lundbeck.

ORLANDO – Making the best use of the right technology can transform a primary care practice, according to Dr. Daniel Feiten.

Parents are living in a mobile world. They do their banking online, they order pizza online, and they want to manage some aspects of their family’s health care online when possible. Many pediatric practices, however, are still living in a typewriter world, said Dr. Feiten, a pediatrician in private practice in Centennial, Colo.

© Catherine Yeulet/iStockphoto

During a session on technology at the annual meeting of the American Academy of Pediatrics, he noted that it’s not always easy to incorporate new technology into an existing practice – and in some cases the transition can actually increase workload. Among those he recommended as potentially cost-effective and worth considering are a website with a symptom checker, and a digital answering service.

A survey of parents from his group practice showed that for 56%, the main reason for visiting the practice’s website was having a sick child. They wanted to know if their child needed to be seen by a doctor, and they wanted access to a symptom checker to help them determine that, Dr. Feiten said.

In another survey of 2,600 parents who have used such a symptom checker, 61% said the application saved them a call to the doctor’s office, 19% said it prompted them to call when they weren’t planning to do so, and 93% said they would prefer to find the symptom checker on the doctor’s website rather than having to use another source.

Furthermore, 93% of respondents said the symptom checker was the most important feature, and 72% listed patient portals (for appointment requests and other communications) as an important feature as well.

A third of them considered physician and staff photos to be important.

"What does that say? It says that we are moving away from the mentality of using a website or a web presence to get patients," Dr. Feiten said, explaining that the functionality parents want is a simple, quick way to determine whether their children need medical care.

"Websites should be functional tools rather than marketing tools," he said.

The symptom checker should be the prominent feature of the website – available on the home page, with easy access and drop-downs, he said.

An analysis in his practice showed that while the impact on answering service calls was minimal 5 years after launching a website with a symptom checker, the parents who said they used the website brought in $19,000 that year.

"That’s a nice return on investment for the little you would pay to have a symptom checker on your website," he said.

Dr. Feiten said that digital answering service applications allow patients to page an on-call physician via the website or a mobile phone. The applications direct parents to write concise descriptions of their children’s symptoms, and the programs can be adapted to direct pages "to the right person at the right time on the right device."

The relatively new technology offers a number of advantages over live answering services – not the least of which is improved accuracy for electronic health records. Consider the spelling of a patient’s name, for example. (How many ways are there to spell ‘Michaela?’ Dr. Feiten, mused). A parent will get it right, he said.

The applications are also easy to implement on a website or mobile device, and the cost is half (or less) that of live instant message answering services, according to Dr. Feiten, who predicted that "this will be the next revolution in after-hours."

Potential savings in the United States is $34 million each year, he said.

His practice has been using the service for 2 years, and an analysis showed that only 1 in 84 parents said they expected the availability of the service would increase the number of after-hours calls they make, and in fact, after implementation, visit volume increased 5%, but after-hours message volume increased by only 1.2%.

"The feedback that we get from parents is that they love this type of service," he said.

Many practices may find that it is best to make both types of answering services available, as not all parents will embrace this technology.

A related technology that has the potential to improve communications between physicians, and which a number of companies are currently developing, is message management software, he noted.

It will provide an efficient system to get messages quickly to the intended recipient, with criteria built in to ensure messages aren’t missed (such as live-agent validation for messages that aren’t picked up in a timely manner).

"I’m really excited about this," Dr. Feiten said, explaining that these "rules engine" applications are "the wave of the future."

Dr. Feiten is cofounder of MedSecure (an answering service), and cofounder and co-owner of Remedy Web Inc. (a web design and development company), but he receives no remuneration from these companies. He is on the board of directors of the Children’s Diabetes Foundation.

pdnews@frontlinemedcom.com

ORLANDO – Making the best use of the right technology can transform a primary care practice, according to Dr. Daniel Feiten.

Parents are living in a mobile world. They do their banking online, they order pizza online, and they want to manage some aspects of their family’s health care online when possible. Many pediatric practices, however, are still living in a typewriter world, said Dr. Feiten, a pediatrician in private practice in Centennial, Colo.

© Catherine Yeulet/iStockphoto

During a session on technology at the annual meeting of the American Academy of Pediatrics, he noted that it’s not always easy to incorporate new technology into an existing practice – and in some cases the transition can actually increase workload. Among those he recommended as potentially cost-effective and worth considering are a website with a symptom checker, and a digital answering service.

A survey of parents from his group practice showed that for 56%, the main reason for visiting the practice’s website was having a sick child. They wanted to know if their child needed to be seen by a doctor, and they wanted access to a symptom checker to help them determine that, Dr. Feiten said.

In another survey of 2,600 parents who have used such a symptom checker, 61% said the application saved them a call to the doctor’s office, 19% said it prompted them to call when they weren’t planning to do so, and 93% said they would prefer to find the symptom checker on the doctor’s website rather than having to use another source.

Furthermore, 93% of respondents said the symptom checker was the most important feature, and 72% listed patient portals (for appointment requests and other communications) as an important feature as well.

A third of them considered physician and staff photos to be important.

"What does that say? It says that we are moving away from the mentality of using a website or a web presence to get patients," Dr. Feiten said, explaining that the functionality parents want is a simple, quick way to determine whether their children need medical care.

"Websites should be functional tools rather than marketing tools," he said.

The symptom checker should be the prominent feature of the website – available on the home page, with easy access and drop-downs, he said.

An analysis in his practice showed that while the impact on answering service calls was minimal 5 years after launching a website with a symptom checker, the parents who said they used the website brought in $19,000 that year.

"That’s a nice return on investment for the little you would pay to have a symptom checker on your website," he said.

Dr. Feiten said that digital answering service applications allow patients to page an on-call physician via the website or a mobile phone. The applications direct parents to write concise descriptions of their children’s symptoms, and the programs can be adapted to direct pages "to the right person at the right time on the right device."

The relatively new technology offers a number of advantages over live answering services – not the least of which is improved accuracy for electronic health records. Consider the spelling of a patient’s name, for example. (How many ways are there to spell ‘Michaela?’ Dr. Feiten, mused). A parent will get it right, he said.

The applications are also easy to implement on a website or mobile device, and the cost is half (or less) that of live instant message answering services, according to Dr. Feiten, who predicted that "this will be the next revolution in after-hours."

Potential savings in the United States is $34 million each year, he said.

His practice has been using the service for 2 years, and an analysis showed that only 1 in 84 parents said they expected the availability of the service would increase the number of after-hours calls they make, and in fact, after implementation, visit volume increased 5%, but after-hours message volume increased by only 1.2%.

"The feedback that we get from parents is that they love this type of service," he said.

Many practices may find that it is best to make both types of answering services available, as not all parents will embrace this technology.

A related technology that has the potential to improve communications between physicians, and which a number of companies are currently developing, is message management software, he noted.

It will provide an efficient system to get messages quickly to the intended recipient, with criteria built in to ensure messages aren’t missed (such as live-agent validation for messages that aren’t picked up in a timely manner).

"I’m really excited about this," Dr. Feiten said, explaining that these "rules engine" applications are "the wave of the future."

Dr. Feiten is cofounder of MedSecure (an answering service), and cofounder and co-owner of Remedy Web Inc. (a web design and development company), but he receives no remuneration from these companies. He is on the board of directors of the Children’s Diabetes Foundation.

pdnews@frontlinemedcom.com

ORLANDO – Making the best use of the right technology can transform a primary care practice, according to Dr. Daniel Feiten.

Parents are living in a mobile world. They do their banking online, they order pizza online, and they want to manage some aspects of their family’s health care online when possible. Many pediatric practices, however, are still living in a typewriter world, said Dr. Feiten, a pediatrician in private practice in Centennial, Colo.

© Catherine Yeulet/iStockphoto

During a session on technology at the annual meeting of the American Academy of Pediatrics, he noted that it’s not always easy to incorporate new technology into an existing practice – and in some cases the transition can actually increase workload. Among those he recommended as potentially cost-effective and worth considering are a website with a symptom checker, and a digital answering service.

A survey of parents from his group practice showed that for 56%, the main reason for visiting the practice’s website was having a sick child. They wanted to know if their child needed to be seen by a doctor, and they wanted access to a symptom checker to help them determine that, Dr. Feiten said.

In another survey of 2,600 parents who have used such a symptom checker, 61% said the application saved them a call to the doctor’s office, 19% said it prompted them to call when they weren’t planning to do so, and 93% said they would prefer to find the symptom checker on the doctor’s website rather than having to use another source.

Furthermore, 93% of respondents said the symptom checker was the most important feature, and 72% listed patient portals (for appointment requests and other communications) as an important feature as well.

A third of them considered physician and staff photos to be important.

"What does that say? It says that we are moving away from the mentality of using a website or a web presence to get patients," Dr. Feiten said, explaining that the functionality parents want is a simple, quick way to determine whether their children need medical care.

"Websites should be functional tools rather than marketing tools," he said.

The symptom checker should be the prominent feature of the website – available on the home page, with easy access and drop-downs, he said.

An analysis in his practice showed that while the impact on answering service calls was minimal 5 years after launching a website with a symptom checker, the parents who said they used the website brought in $19,000 that year.

"That’s a nice return on investment for the little you would pay to have a symptom checker on your website," he said.

Dr. Feiten said that digital answering service applications allow patients to page an on-call physician via the website or a mobile phone. The applications direct parents to write concise descriptions of their children’s symptoms, and the programs can be adapted to direct pages "to the right person at the right time on the right device."

The relatively new technology offers a number of advantages over live answering services – not the least of which is improved accuracy for electronic health records. Consider the spelling of a patient’s name, for example. (How many ways are there to spell ‘Michaela?’ Dr. Feiten, mused). A parent will get it right, he said.

The applications are also easy to implement on a website or mobile device, and the cost is half (or less) that of live instant message answering services, according to Dr. Feiten, who predicted that "this will be the next revolution in after-hours."

Potential savings in the United States is $34 million each year, he said.

His practice has been using the service for 2 years, and an analysis showed that only 1 in 84 parents said they expected the availability of the service would increase the number of after-hours calls they make, and in fact, after implementation, visit volume increased 5%, but after-hours message volume increased by only 1.2%.

"The feedback that we get from parents is that they love this type of service," he said.

Many practices may find that it is best to make both types of answering services available, as not all parents will embrace this technology.

A related technology that has the potential to improve communications between physicians, and which a number of companies are currently developing, is message management software, he noted.

It will provide an efficient system to get messages quickly to the intended recipient, with criteria built in to ensure messages aren’t missed (such as live-agent validation for messages that aren’t picked up in a timely manner).

"I’m really excited about this," Dr. Feiten said, explaining that these "rules engine" applications are "the wave of the future."

Dr. Feiten is cofounder of MedSecure (an answering service), and cofounder and co-owner of Remedy Web Inc. (a web design and development company), but he receives no remuneration from these companies. He is on the board of directors of the Children’s Diabetes Foundation.

pdnews@frontlinemedcom.com

WASHINGTON – Resective epilepsy surgery yielded favorable long-term outcomes with respect to both seizure frequency and psychosocial factors in the majority of adult patients who participated in a recent survey.

Of 253 respondents, 82 (32%) were free of seizures at a mean of 10.6 years after surgery, and 189 (75%) had a favorable outcome, defined as Engel’s Class I or II surgery outcome, Dr. Marianna V. Spanaki-Varelas reported in a poster at the annual meeting of the American Epilepsy Society.

Overall, more than half (51%) of the patients were driving after surgery, compared with 35% before surgery, Dr. Spanaki-Varelas of Henry Ford Comprehensive Epilepsy Program, Detroit.

Respondents were less likely currently to be working full time when surveyed vs. prior to surgery (23% vs. 42%), but employment was greater in the 85% of patients who underwent temporal vs. extratemporal resection (45% vs. 26%).

Also, more patients were using antidepressants after surgery, compared with before surgery (30% vs. 22%).

Among the patients with favorable outcomes, 65% were driving after surgery (compared with 11% of those without a favorable outcome), 28% were currently employed, (compared with 8% of those without favorable outcomes), and only 24% were taking antidepressants (compared with 47% of those without a favorable outcome).

Perhaps most notable was that regardless of surgery site, 92% of respondents considered epilepsy surgery worthwhile, including 98% of those with a favorable outcome and 74% of those without a favorable outcome.

Even in patients without a favorable outcome, seizure frequency was often reduced and patients were satisfied, she explained, noting that the findings reinforce the importance of quality of life – and the ability of surgery to enhance quality of life, and they suggest that referral for surgery should be considered earlier in the course of treatment.

The respondents had a mean age of 46 years at the time of the survey, a mean age of nearly 16 years at epilepsy diagnosis, and a mean age of 35 years at the time of surgery, which took place at the Henry Ford Epilepsy Program between 1993 and 2011. Patient records were retrospectively reviewed, and the patients were surveyed between May 2012 and January 2013.

Nearly a third (30%) had follow-up of at least 20 years, Dr. Spanaki-Varelas noted.

It is concerning that potentially life-changing surgery is being delayed nearly 20 years for many patients, she said, noting that part of the reason for delay is the common misconception that the more medications a patient tries, the better their outcome will be. This delays evaluations for surgical intervention. Also, surveys suggest that many physicians don’t refer patients for surgical evaluation because they don’t feel confident regarding their knowledge of the risks and benefits of surgery.

These findings underscore the need for better patient education, which may improve self-referral rates, she said.

WASHINGTON – Resective epilepsy surgery yielded favorable long-term outcomes with respect to both seizure frequency and psychosocial factors in the majority of adult patients who participated in a recent survey.

Of 253 respondents, 82 (32%) were free of seizures at a mean of 10.6 years after surgery, and 189 (75%) had a favorable outcome, defined as Engel’s Class I or II surgery outcome, Dr. Marianna V. Spanaki-Varelas reported in a poster at the annual meeting of the American Epilepsy Society.

Overall, more than half (51%) of the patients were driving after surgery, compared with 35% before surgery, Dr. Spanaki-Varelas of Henry Ford Comprehensive Epilepsy Program, Detroit.

Respondents were less likely currently to be working full time when surveyed vs. prior to surgery (23% vs. 42%), but employment was greater in the 85% of patients who underwent temporal vs. extratemporal resection (45% vs. 26%).

Also, more patients were using antidepressants after surgery, compared with before surgery (30% vs. 22%).

Among the patients with favorable outcomes, 65% were driving after surgery (compared with 11% of those without a favorable outcome), 28% were currently employed, (compared with 8% of those without favorable outcomes), and only 24% were taking antidepressants (compared with 47% of those without a favorable outcome).

Perhaps most notable was that regardless of surgery site, 92% of respondents considered epilepsy surgery worthwhile, including 98% of those with a favorable outcome and 74% of those without a favorable outcome.

Even in patients without a favorable outcome, seizure frequency was often reduced and patients were satisfied, she explained, noting that the findings reinforce the importance of quality of life – and the ability of surgery to enhance quality of life, and they suggest that referral for surgery should be considered earlier in the course of treatment.

The respondents had a mean age of 46 years at the time of the survey, a mean age of nearly 16 years at epilepsy diagnosis, and a mean age of 35 years at the time of surgery, which took place at the Henry Ford Epilepsy Program between 1993 and 2011. Patient records were retrospectively reviewed, and the patients were surveyed between May 2012 and January 2013.

Nearly a third (30%) had follow-up of at least 20 years, Dr. Spanaki-Varelas noted.

It is concerning that potentially life-changing surgery is being delayed nearly 20 years for many patients, she said, noting that part of the reason for delay is the common misconception that the more medications a patient tries, the better their outcome will be. This delays evaluations for surgical intervention. Also, surveys suggest that many physicians don’t refer patients for surgical evaluation because they don’t feel confident regarding their knowledge of the risks and benefits of surgery.

These findings underscore the need for better patient education, which may improve self-referral rates, she said.

WASHINGTON – Resective epilepsy surgery yielded favorable long-term outcomes with respect to both seizure frequency and psychosocial factors in the majority of adult patients who participated in a recent survey.

Of 253 respondents, 82 (32%) were free of seizures at a mean of 10.6 years after surgery, and 189 (75%) had a favorable outcome, defined as Engel’s Class I or II surgery outcome, Dr. Marianna V. Spanaki-Varelas reported in a poster at the annual meeting of the American Epilepsy Society.

Overall, more than half (51%) of the patients were driving after surgery, compared with 35% before surgery, Dr. Spanaki-Varelas of Henry Ford Comprehensive Epilepsy Program, Detroit.

Respondents were less likely currently to be working full time when surveyed vs. prior to surgery (23% vs. 42%), but employment was greater in the 85% of patients who underwent temporal vs. extratemporal resection (45% vs. 26%).

Also, more patients were using antidepressants after surgery, compared with before surgery (30% vs. 22%).

Among the patients with favorable outcomes, 65% were driving after surgery (compared with 11% of those without a favorable outcome), 28% were currently employed, (compared with 8% of those without favorable outcomes), and only 24% were taking antidepressants (compared with 47% of those without a favorable outcome).

Perhaps most notable was that regardless of surgery site, 92% of respondents considered epilepsy surgery worthwhile, including 98% of those with a favorable outcome and 74% of those without a favorable outcome.

Even in patients without a favorable outcome, seizure frequency was often reduced and patients were satisfied, she explained, noting that the findings reinforce the importance of quality of life – and the ability of surgery to enhance quality of life, and they suggest that referral for surgery should be considered earlier in the course of treatment.

The respondents had a mean age of 46 years at the time of the survey, a mean age of nearly 16 years at epilepsy diagnosis, and a mean age of 35 years at the time of surgery, which took place at the Henry Ford Epilepsy Program between 1993 and 2011. Patient records were retrospectively reviewed, and the patients were surveyed between May 2012 and January 2013.

Nearly a third (30%) had follow-up of at least 20 years, Dr. Spanaki-Varelas noted.

It is concerning that potentially life-changing surgery is being delayed nearly 20 years for many patients, she said, noting that part of the reason for delay is the common misconception that the more medications a patient tries, the better their outcome will be. This delays evaluations for surgical intervention. Also, surveys suggest that many physicians don’t refer patients for surgical evaluation because they don’t feel confident regarding their knowledge of the risks and benefits of surgery.

These findings underscore the need for better patient education, which may improve self-referral rates, she said.

Outcomes in patients with rheumatoid arthritis and prior exposure to an anti–tumor necrosis factor drug who switched to a new anti-TNF drug were similar to those in patients with prior anti-TNF exposure who initiated abatacept in a comparative effectiveness trial.

The mean changes in Clinical Disease Activity Index (CDAI) scores; modified American College of Rheumatology (mACR) 20, 50, and 70 responses; modified Health Assessment Questionnaire (mHAQ) scores; and remission rates on the CDAI all were similar at 6 and 12 months after treatment initiation in propensity score-matched groups of patients from the large observational cohort study who either switched anti-TNF drugs or initiated abatacept after exposure to an anti-TNF drug, Dr. Leslie R. Harrold of the University of Massachusetts Medical School, Worcester, and her colleagues reported.

For example, at 6 months in 746 anti-TNF users and 431 abatacept users and at 12 months in 493 anti-TNF users and 311 abatacept users, the mean differences in CDAI scores were 0.46 and –1.64, respectively, after adjustment for number of prior anti-TNF medications, baseline disease activity, rheumatoid arthritis disease severity, and concomitant medications. Also, mACR20 responses at 6 months were 28.2% vs. 31.7%.

At 12 months, 35%-37% of patients in the groups achieved mACR20, 20%-22% achieved mACR50, and 10%-12% achieved mACR70. A meaningful change in mHAQ score was achieved by 30%-33% of patients at 6 months and 29%-30% at 12 months. CDAI remission rates were 9%-10% at 6 months and 12%-14% at 12 months, the investigators said (Ann. Rheum. Dis. 2013 Dec. 2 [doi:10.1136/annrheumdis-2013-203936]).

Patients were Consortium of Rheumatology Researchers of North American (CORRONA) registry participants with exposure to one or more anti-TNF agents but no prior use of non-anti-TNF biologics, according to data from Feb. 1, 2000, to Aug. 1, 2011, the investigators said.

The findings of the current analysis, which is among the first to examine comparative effectiveness of abatacept and anti-TNF agents in those with prior anti-TNF agent exposures, suggest that "just changing the mechanism of action may not be enough to improve disease activity," Dr. Harrold and her associates wrote.

"When discussing next therapeutic interventions in those not responding or unable to take their current anti-TNF agents, these results can potentially contribute to the discussion as patients weigh other factors such as potential adverse events associated with the different agents, out-of pocket costs, and medication route of administration," they said.

Additional comparative effectiveness studies are needed to evaluate the potential benefits of switching to a different non-TNF biologic versus anti-TNF intra-class switching in patients who have an inadequate response to an anti-TNF, they concluded.

CORRONA has received support from Abbott, Amgen, Astra-Zeneca, Genentech, Janssen (Centocor), Eli Lilly, and Pfizer through contracted subscriptions to the database. The investigators reported ties with CORRONA, AbbVie, Amgen, Bristol-Myers Squibb, Genentech, Lilly, Pfizer, UCB, Roche, Janssen, Crescendo, UpToDate, Novartis, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Arthritis Foundation, and/or the Arthritis National Research Foundation.

Outcomes in patients with rheumatoid arthritis and prior exposure to an anti–tumor necrosis factor drug who switched to a new anti-TNF drug were similar to those in patients with prior anti-TNF exposure who initiated abatacept in a comparative effectiveness trial.

The mean changes in Clinical Disease Activity Index (CDAI) scores; modified American College of Rheumatology (mACR) 20, 50, and 70 responses; modified Health Assessment Questionnaire (mHAQ) scores; and remission rates on the CDAI all were similar at 6 and 12 months after treatment initiation in propensity score-matched groups of patients from the large observational cohort study who either switched anti-TNF drugs or initiated abatacept after exposure to an anti-TNF drug, Dr. Leslie R. Harrold of the University of Massachusetts Medical School, Worcester, and her colleagues reported.

For example, at 6 months in 746 anti-TNF users and 431 abatacept users and at 12 months in 493 anti-TNF users and 311 abatacept users, the mean differences in CDAI scores were 0.46 and –1.64, respectively, after adjustment for number of prior anti-TNF medications, baseline disease activity, rheumatoid arthritis disease severity, and concomitant medications. Also, mACR20 responses at 6 months were 28.2% vs. 31.7%.

At 12 months, 35%-37% of patients in the groups achieved mACR20, 20%-22% achieved mACR50, and 10%-12% achieved mACR70. A meaningful change in mHAQ score was achieved by 30%-33% of patients at 6 months and 29%-30% at 12 months. CDAI remission rates were 9%-10% at 6 months and 12%-14% at 12 months, the investigators said (Ann. Rheum. Dis. 2013 Dec. 2 [doi:10.1136/annrheumdis-2013-203936]).

Patients were Consortium of Rheumatology Researchers of North American (CORRONA) registry participants with exposure to one or more anti-TNF agents but no prior use of non-anti-TNF biologics, according to data from Feb. 1, 2000, to Aug. 1, 2011, the investigators said.

The findings of the current analysis, which is among the first to examine comparative effectiveness of abatacept and anti-TNF agents in those with prior anti-TNF agent exposures, suggest that "just changing the mechanism of action may not be enough to improve disease activity," Dr. Harrold and her associates wrote.

"When discussing next therapeutic interventions in those not responding or unable to take their current anti-TNF agents, these results can potentially contribute to the discussion as patients weigh other factors such as potential adverse events associated with the different agents, out-of pocket costs, and medication route of administration," they said.

Additional comparative effectiveness studies are needed to evaluate the potential benefits of switching to a different non-TNF biologic versus anti-TNF intra-class switching in patients who have an inadequate response to an anti-TNF, they concluded.

CORRONA has received support from Abbott, Amgen, Astra-Zeneca, Genentech, Janssen (Centocor), Eli Lilly, and Pfizer through contracted subscriptions to the database. The investigators reported ties with CORRONA, AbbVie, Amgen, Bristol-Myers Squibb, Genentech, Lilly, Pfizer, UCB, Roche, Janssen, Crescendo, UpToDate, Novartis, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Arthritis Foundation, and/or the Arthritis National Research Foundation.

Outcomes in patients with rheumatoid arthritis and prior exposure to an anti–tumor necrosis factor drug who switched to a new anti-TNF drug were similar to those in patients with prior anti-TNF exposure who initiated abatacept in a comparative effectiveness trial.

The mean changes in Clinical Disease Activity Index (CDAI) scores; modified American College of Rheumatology (mACR) 20, 50, and 70 responses; modified Health Assessment Questionnaire (mHAQ) scores; and remission rates on the CDAI all were similar at 6 and 12 months after treatment initiation in propensity score-matched groups of patients from the large observational cohort study who either switched anti-TNF drugs or initiated abatacept after exposure to an anti-TNF drug, Dr. Leslie R. Harrold of the University of Massachusetts Medical School, Worcester, and her colleagues reported.

For example, at 6 months in 746 anti-TNF users and 431 abatacept users and at 12 months in 493 anti-TNF users and 311 abatacept users, the mean differences in CDAI scores were 0.46 and –1.64, respectively, after adjustment for number of prior anti-TNF medications, baseline disease activity, rheumatoid arthritis disease severity, and concomitant medications. Also, mACR20 responses at 6 months were 28.2% vs. 31.7%.

At 12 months, 35%-37% of patients in the groups achieved mACR20, 20%-22% achieved mACR50, and 10%-12% achieved mACR70. A meaningful change in mHAQ score was achieved by 30%-33% of patients at 6 months and 29%-30% at 12 months. CDAI remission rates were 9%-10% at 6 months and 12%-14% at 12 months, the investigators said (Ann. Rheum. Dis. 2013 Dec. 2 [doi:10.1136/annrheumdis-2013-203936]).

Patients were Consortium of Rheumatology Researchers of North American (CORRONA) registry participants with exposure to one or more anti-TNF agents but no prior use of non-anti-TNF biologics, according to data from Feb. 1, 2000, to Aug. 1, 2011, the investigators said.

The findings of the current analysis, which is among the first to examine comparative effectiveness of abatacept and anti-TNF agents in those with prior anti-TNF agent exposures, suggest that "just changing the mechanism of action may not be enough to improve disease activity," Dr. Harrold and her associates wrote.

"When discussing next therapeutic interventions in those not responding or unable to take their current anti-TNF agents, these results can potentially contribute to the discussion as patients weigh other factors such as potential adverse events associated with the different agents, out-of pocket costs, and medication route of administration," they said.

Additional comparative effectiveness studies are needed to evaluate the potential benefits of switching to a different non-TNF biologic versus anti-TNF intra-class switching in patients who have an inadequate response to an anti-TNF, they concluded.

CORRONA has received support from Abbott, Amgen, Astra-Zeneca, Genentech, Janssen (Centocor), Eli Lilly, and Pfizer through contracted subscriptions to the database. The investigators reported ties with CORRONA, AbbVie, Amgen, Bristol-Myers Squibb, Genentech, Lilly, Pfizer, UCB, Roche, Janssen, Crescendo, UpToDate, Novartis, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Arthritis Foundation, and/or the Arthritis National Research Foundation.

WASHINGTON – The vast majority of 100 children who underwent surgical resection for epilepsy at a single center experienced stable or significantly improved mood and anxiety symptoms after surgery.

The findings, which demonstrated good overall outcomes but differential effects based on site and side of surgery, have important implications for counseling parents about the potential effects of surgery, Elizabeth N. Andresen, Ph.D., reported at the annual meeting of the American Epilepsy Society.

The findings are important, because children with epilepsy are at high risk for depression, anxiety, and behavior problems. For example, children with epilepsy are 4.8 times more likely than are children in the general population, and 2.5 times more likely than those with other chronic conditions to develop such disturbances.

Parents are understandably concerned about how surgery might affect their child’s mood, behavior, and personality, and the few prior studies available have provided conflicting results, Dr. Andresen said.

"Now we have some good data that show that kids tend to do well: They tend to be the same, they tend to be pretty happy afterward, they tend to get better," she said.

Presurgically, 36 children with frontal lobe epilepsy reported symptoms of withdrawal and anxiety more often than did 64 children with temporal lobe epilepsy, but these symptoms improved significantly after surgery to levels comparable to or better than those in the temporal lobe epilepsy patients.

This finding was most pronounced among those who underwent left-sided surgery, Dr. Andresen of the Cleveland Clinic said at a press briefing during the meeting.

For example, presurgical T scores for anhedonia, social anxiety, and withdrawn/depression symptoms in frontal lobe vs. temporal lobe epilepsy patients who underwent left-sided surgery were 59 vs. 50, 59 vs. 49, and 59 vs. 58, respectively; after surgery, the T scores were 50 vs. 50, 42 vs. 48, and 55 vs. 59, respectively.

Scores for patients who underwent left-sided surgery significantly improved in evaluations at about 10 months on the social anxiety subscale of the Revised Children’s Manifest Anxiety Scale (RCMAS) and the withdrawal subscale of the Achenbach Child Behavior Checklist (CBCL). Surgical site or type of epilepsy did not appear to influence general improvement on the negative mood subscale of the Children’s Depression Inventory (CDI) and the worry subscale of the RCMAS, Dr. Andresen said.

Similarly, the improvement seen over time across the groups on the withdrawal, social problems, thought problems, and attention problems subscales of the CBCL did not appear to be related to the surgical site.

At the individual level, change scores on the CDI and RCMAS demonstrated clinically significant improvement in overall depression symptoms in 21% of patients overall, including 15% of temporal lobe patients and 33% of frontal lobe epilepsy patients, and in overall anxiety symptoms in 38% of patients overall, including 27% of temporal lobe epilepsy patients and 45% of frontal lobe epilepsy patients.

Particularly pronounced effects were seen with respect to anhedonia and social anxiety in those with frontal lobe epilepsy who underwent left-sided surgery, with 63% and 100% of those patients experiencing improvement on those measures, respectively.

When children with and without depression prior to surgery were analyzed separately, Dr. Andresen found that only 6% of those without depression developed depression after surgery, while 64% of those with depression before surgery were no longer depressed after surgery. Similarly, 11% of those without anxiety before surgery developed anxiety after surgery, while 40% of those with anxiety before surgery were not anxious after surgery.

The proportion of surgery patients developing new depression and anxiety was similar to the proportion of nonsurgical control patients who developed depression or anxiety over 6 months (6% and 15%), Dr. Andresen noted.

"So it looks like surgery isn’t having a big effect on the rate of new problems," she said, noting that while it isn’t having a huge effect "on the rate of making those problems go away," the numbers are moving in the right direction.

Of 64 patients treated for temporal lobe epilepsy, 38 underwent left-sided surgery and 26 underwent right-sided surgery. The other group of 36 patients with frontal lobe epilepsy included 16 who underwent left-sided surgery and 20 who underwent right-sided surgery. Another 53 patients who did not undergo surgery served as controls. Children included in the study were aged 5-16 years (mean of 11 years) with a mean age of epilepsy onset at 5.8 years and a mean duration of 5.3 years. All were taking at least two antiepileptic drugs.

Dr. Andresen said that she had no disclosures.

WASHINGTON – The vast majority of 100 children who underwent surgical resection for epilepsy at a single center experienced stable or significantly improved mood and anxiety symptoms after surgery.

The findings, which demonstrated good overall outcomes but differential effects based on site and side of surgery, have important implications for counseling parents about the potential effects of surgery, Elizabeth N. Andresen, Ph.D., reported at the annual meeting of the American Epilepsy Society.

The findings are important, because children with epilepsy are at high risk for depression, anxiety, and behavior problems. For example, children with epilepsy are 4.8 times more likely than are children in the general population, and 2.5 times more likely than those with other chronic conditions to develop such disturbances.

Parents are understandably concerned about how surgery might affect their child’s mood, behavior, and personality, and the few prior studies available have provided conflicting results, Dr. Andresen said.

"Now we have some good data that show that kids tend to do well: They tend to be the same, they tend to be pretty happy afterward, they tend to get better," she said.

Presurgically, 36 children with frontal lobe epilepsy reported symptoms of withdrawal and anxiety more often than did 64 children with temporal lobe epilepsy, but these symptoms improved significantly after surgery to levels comparable to or better than those in the temporal lobe epilepsy patients.

This finding was most pronounced among those who underwent left-sided surgery, Dr. Andresen of the Cleveland Clinic said at a press briefing during the meeting.

For example, presurgical T scores for anhedonia, social anxiety, and withdrawn/depression symptoms in frontal lobe vs. temporal lobe epilepsy patients who underwent left-sided surgery were 59 vs. 50, 59 vs. 49, and 59 vs. 58, respectively; after surgery, the T scores were 50 vs. 50, 42 vs. 48, and 55 vs. 59, respectively.

Scores for patients who underwent left-sided surgery significantly improved in evaluations at about 10 months on the social anxiety subscale of the Revised Children’s Manifest Anxiety Scale (RCMAS) and the withdrawal subscale of the Achenbach Child Behavior Checklist (CBCL). Surgical site or type of epilepsy did not appear to influence general improvement on the negative mood subscale of the Children’s Depression Inventory (CDI) and the worry subscale of the RCMAS, Dr. Andresen said.

Similarly, the improvement seen over time across the groups on the withdrawal, social problems, thought problems, and attention problems subscales of the CBCL did not appear to be related to the surgical site.

At the individual level, change scores on the CDI and RCMAS demonstrated clinically significant improvement in overall depression symptoms in 21% of patients overall, including 15% of temporal lobe patients and 33% of frontal lobe epilepsy patients, and in overall anxiety symptoms in 38% of patients overall, including 27% of temporal lobe epilepsy patients and 45% of frontal lobe epilepsy patients.

Particularly pronounced effects were seen with respect to anhedonia and social anxiety in those with frontal lobe epilepsy who underwent left-sided surgery, with 63% and 100% of those patients experiencing improvement on those measures, respectively.

When children with and without depression prior to surgery were analyzed separately, Dr. Andresen found that only 6% of those without depression developed depression after surgery, while 64% of those with depression before surgery were no longer depressed after surgery. Similarly, 11% of those without anxiety before surgery developed anxiety after surgery, while 40% of those with anxiety before surgery were not anxious after surgery.

The proportion of surgery patients developing new depression and anxiety was similar to the proportion of nonsurgical control patients who developed depression or anxiety over 6 months (6% and 15%), Dr. Andresen noted.

"So it looks like surgery isn’t having a big effect on the rate of new problems," she said, noting that while it isn’t having a huge effect "on the rate of making those problems go away," the numbers are moving in the right direction.

Of 64 patients treated for temporal lobe epilepsy, 38 underwent left-sided surgery and 26 underwent right-sided surgery. The other group of 36 patients with frontal lobe epilepsy included 16 who underwent left-sided surgery and 20 who underwent right-sided surgery. Another 53 patients who did not undergo surgery served as controls. Children included in the study were aged 5-16 years (mean of 11 years) with a mean age of epilepsy onset at 5.8 years and a mean duration of 5.3 years. All were taking at least two antiepileptic drugs.

Dr. Andresen said that she had no disclosures.

WASHINGTON – The vast majority of 100 children who underwent surgical resection for epilepsy at a single center experienced stable or significantly improved mood and anxiety symptoms after surgery.

The findings, which demonstrated good overall outcomes but differential effects based on site and side of surgery, have important implications for counseling parents about the potential effects of surgery, Elizabeth N. Andresen, Ph.D., reported at the annual meeting of the American Epilepsy Society.

The findings are important, because children with epilepsy are at high risk for depression, anxiety, and behavior problems. For example, children with epilepsy are 4.8 times more likely than are children in the general population, and 2.5 times more likely than those with other chronic conditions to develop such disturbances.

Parents are understandably concerned about how surgery might affect their child’s mood, behavior, and personality, and the few prior studies available have provided conflicting results, Dr. Andresen said.

"Now we have some good data that show that kids tend to do well: They tend to be the same, they tend to be pretty happy afterward, they tend to get better," she said.

Presurgically, 36 children with frontal lobe epilepsy reported symptoms of withdrawal and anxiety more often than did 64 children with temporal lobe epilepsy, but these symptoms improved significantly after surgery to levels comparable to or better than those in the temporal lobe epilepsy patients.

This finding was most pronounced among those who underwent left-sided surgery, Dr. Andresen of the Cleveland Clinic said at a press briefing during the meeting.

For example, presurgical T scores for anhedonia, social anxiety, and withdrawn/depression symptoms in frontal lobe vs. temporal lobe epilepsy patients who underwent left-sided surgery were 59 vs. 50, 59 vs. 49, and 59 vs. 58, respectively; after surgery, the T scores were 50 vs. 50, 42 vs. 48, and 55 vs. 59, respectively.

Scores for patients who underwent left-sided surgery significantly improved in evaluations at about 10 months on the social anxiety subscale of the Revised Children’s Manifest Anxiety Scale (RCMAS) and the withdrawal subscale of the Achenbach Child Behavior Checklist (CBCL). Surgical site or type of epilepsy did not appear to influence general improvement on the negative mood subscale of the Children’s Depression Inventory (CDI) and the worry subscale of the RCMAS, Dr. Andresen said.

Similarly, the improvement seen over time across the groups on the withdrawal, social problems, thought problems, and attention problems subscales of the CBCL did not appear to be related to the surgical site.

At the individual level, change scores on the CDI and RCMAS demonstrated clinically significant improvement in overall depression symptoms in 21% of patients overall, including 15% of temporal lobe patients and 33% of frontal lobe epilepsy patients, and in overall anxiety symptoms in 38% of patients overall, including 27% of temporal lobe epilepsy patients and 45% of frontal lobe epilepsy patients.

Particularly pronounced effects were seen with respect to anhedonia and social anxiety in those with frontal lobe epilepsy who underwent left-sided surgery, with 63% and 100% of those patients experiencing improvement on those measures, respectively.

When children with and without depression prior to surgery were analyzed separately, Dr. Andresen found that only 6% of those without depression developed depression after surgery, while 64% of those with depression before surgery were no longer depressed after surgery. Similarly, 11% of those without anxiety before surgery developed anxiety after surgery, while 40% of those with anxiety before surgery were not anxious after surgery.

The proportion of surgery patients developing new depression and anxiety was similar to the proportion of nonsurgical control patients who developed depression or anxiety over 6 months (6% and 15%), Dr. Andresen noted.

"So it looks like surgery isn’t having a big effect on the rate of new problems," she said, noting that while it isn’t having a huge effect "on the rate of making those problems go away," the numbers are moving in the right direction.

Of 64 patients treated for temporal lobe epilepsy, 38 underwent left-sided surgery and 26 underwent right-sided surgery. The other group of 36 patients with frontal lobe epilepsy included 16 who underwent left-sided surgery and 20 who underwent right-sided surgery. Another 53 patients who did not undergo surgery served as controls. Children included in the study were aged 5-16 years (mean of 11 years) with a mean age of epilepsy onset at 5.8 years and a mean duration of 5.3 years. All were taking at least two antiepileptic drugs.

Dr. Andresen said that she had no disclosures.

Men who continue smoking after a cancer diagnosis have significantly greater risk of death from any cause than did those who quit smoking at the time of diagnosis, according to findings from the prospective population-based Shanghai Cohort Study.

Of 1,632 men from that ongoing study who developed cancer after enrollment and who were eligible for the current analysis, 931 died during 25 years of follow-up, and 747 of those who died were smokers at the time of their cancer diagnosis. Of these smokers, 214 (29%) quit at the time of diagnosis, 197 (26%) smoked persistently after diagnosis, and 336 (45%) smoked intermittently after diagnosis.

©ricky_68fr/fotolia.com

After the researchers adjusted for age at diagnosis, education, cumulative number of pack-years of prediagnosis smoking, cancer site, and treatment modalities, the risk of death was 76% greater in those who smoked persistently or intermittently after diagnosis, compared with those who quit at diagnosis, reported Dr. Li Tao of the Cancer Prevention Institute of California, Fremont, and her colleagues.

Median survival was 2.1 years after diagnosis for those who continued smoking, compared with 4.4 years for those who quit, the investigators said.

Using a time-dependent approach, and including all patients with cancer, the overall risk of mortality was 59% greater for smokers vs. nonsmokers after cancer diagnosis.

"When analyzed separately for cancer specific patients, the multivariate-adjusted hazard ratios of death for smoking relative to nonsmoking after cancer diagnosis were 1.92 for patients with lung cancer, 1.76 for patients with stomach cancer, 1.65 for patients with colorectal cancer, and 3.66 for patients with bladder cancer," the investigators wrote.

In a similar analysis that included only current smokers at cancer diagnosis, smoking after cancer diagnosis was associated with a 79% increase risk of death relative to nonsmoking after diagnosis for all patients.

"Among cancer-specific patients, the [hazard ratios] of death for smoking vs. nonsmoking after cancer diagnosis were 2.36 in patients with lung cancer, 1.63 in patients with stomach cancer, 2.31 in patients with colorectal cancer, 2.95 in patients with bladder cancer, 2.27 in patients with prostate cancer, and 1.34 in all other patient with cancer," the investigators said (Cancer Epidemiol. Biomarkers Prev. 2013;22:2404-11).

The Shanghai Cohort Study is investigating the association between lifestyle characteristics and cancer development in more than 18,000 middle-age or older men who were enrolled between Jan.1, 1986, and Sept. 30, 1989. Smoking status is ascertained via annual in-person interviews. Patients in the current analysis had a mean age of 68.8 years and were followed for a mean of 5.3 years after cancer diagnosis. They had a median survival time of 5.4 years after diagnosis.

The findings provide new information about smoking and cancer survival, the investigators said, noting that cancer is the leading cause of death among men in China, and the second leading cause of death among men in the United States.

Tobacco use is the most important recognized cause of cancer-related death, they said, adding that strong evidence demonstrates an association between smoking and cancer risk, and between improved health and smoking cessation.

The impact of smoking after a cancer diagnosis, however, has not been well studied, and existing data are conflicting, they noted.

The findings of the present study, which have important public health implications for cancer survivors, health care providers, and policy makers, underscore the importance of smoking cessation interventions – and the potential benefit of cessation on survival – in patients who are diagnosed with cancer, they said.

Although patients diagnosed with cancer are expected to "show great interest and motivation to quit smoking," many face physical, psychological, and social stress that impedes their ability to do so. Furthermore, only about 50% of smokers diagnosed with cancer in the United States receive formal smoking cessation counseling at diagnosis, during treatment, or during follow-up visits, they noted.

"Therefore, there is noticeable room for the improvement of self-managed or health care provider–assisted smoking cessation in the clinical setting of patients with cancer," they wrote, also noting that the message about inferior survival among those who continue smoking after a cancer diagnosis should be conveyed to patients and their families, and should be included in guidelines and evidence-based clinical practices.

This study has considerable strengths – such as knowledge of baseline smoking status and the prospective design. It also has limitations, including limited treatment data and inclusion of only patients who survived 1 or more years after cancer diagnosis.

Nonetheless, the findings provide strong support for smoking cessation intervention programs that target cancer survivors and should inform future research into the contextual and individual-level factors that may result in inadequate attention to smoking among patients with cancer in the post diagnosis setting, the investigators concluded.

This study was supported by grants from the United States Public Health Service. The costs of publication were defrayed in part by the payment of page charges. The authors reported having no disclosures.

Men who continue smoking after a cancer diagnosis have significantly greater risk of death from any cause than did those who quit smoking at the time of diagnosis, according to findings from the prospective population-based Shanghai Cohort Study.

Of 1,632 men from that ongoing study who developed cancer after enrollment and who were eligible for the current analysis, 931 died during 25 years of follow-up, and 747 of those who died were smokers at the time of their cancer diagnosis. Of these smokers, 214 (29%) quit at the time of diagnosis, 197 (26%) smoked persistently after diagnosis, and 336 (45%) smoked intermittently after diagnosis.

©ricky_68fr/fotolia.com

After the researchers adjusted for age at diagnosis, education, cumulative number of pack-years of prediagnosis smoking, cancer site, and treatment modalities, the risk of death was 76% greater in those who smoked persistently or intermittently after diagnosis, compared with those who quit at diagnosis, reported Dr. Li Tao of the Cancer Prevention Institute of California, Fremont, and her colleagues.

Median survival was 2.1 years after diagnosis for those who continued smoking, compared with 4.4 years for those who quit, the investigators said.

Using a time-dependent approach, and including all patients with cancer, the overall risk of mortality was 59% greater for smokers vs. nonsmokers after cancer diagnosis.

"When analyzed separately for cancer specific patients, the multivariate-adjusted hazard ratios of death for smoking relative to nonsmoking after cancer diagnosis were 1.92 for patients with lung cancer, 1.76 for patients with stomach cancer, 1.65 for patients with colorectal cancer, and 3.66 for patients with bladder cancer," the investigators wrote.

In a similar analysis that included only current smokers at cancer diagnosis, smoking after cancer diagnosis was associated with a 79% increase risk of death relative to nonsmoking after diagnosis for all patients.

"Among cancer-specific patients, the [hazard ratios] of death for smoking vs. nonsmoking after cancer diagnosis were 2.36 in patients with lung cancer, 1.63 in patients with stomach cancer, 2.31 in patients with colorectal cancer, 2.95 in patients with bladder cancer, 2.27 in patients with prostate cancer, and 1.34 in all other patient with cancer," the investigators said (Cancer Epidemiol. Biomarkers Prev. 2013;22:2404-11).

The Shanghai Cohort Study is investigating the association between lifestyle characteristics and cancer development in more than 18,000 middle-age or older men who were enrolled between Jan.1, 1986, and Sept. 30, 1989. Smoking status is ascertained via annual in-person interviews. Patients in the current analysis had a mean age of 68.8 years and were followed for a mean of 5.3 years after cancer diagnosis. They had a median survival time of 5.4 years after diagnosis.

The findings provide new information about smoking and cancer survival, the investigators said, noting that cancer is the leading cause of death among men in China, and the second leading cause of death among men in the United States.

Tobacco use is the most important recognized cause of cancer-related death, they said, adding that strong evidence demonstrates an association between smoking and cancer risk, and between improved health and smoking cessation.

The impact of smoking after a cancer diagnosis, however, has not been well studied, and existing data are conflicting, they noted.

The findings of the present study, which have important public health implications for cancer survivors, health care providers, and policy makers, underscore the importance of smoking cessation interventions – and the potential benefit of cessation on survival – in patients who are diagnosed with cancer, they said.

Although patients diagnosed with cancer are expected to "show great interest and motivation to quit smoking," many face physical, psychological, and social stress that impedes their ability to do so. Furthermore, only about 50% of smokers diagnosed with cancer in the United States receive formal smoking cessation counseling at diagnosis, during treatment, or during follow-up visits, they noted.

"Therefore, there is noticeable room for the improvement of self-managed or health care provider–assisted smoking cessation in the clinical setting of patients with cancer," they wrote, also noting that the message about inferior survival among those who continue smoking after a cancer diagnosis should be conveyed to patients and their families, and should be included in guidelines and evidence-based clinical practices.

This study has considerable strengths – such as knowledge of baseline smoking status and the prospective design. It also has limitations, including limited treatment data and inclusion of only patients who survived 1 or more years after cancer diagnosis.

Nonetheless, the findings provide strong support for smoking cessation intervention programs that target cancer survivors and should inform future research into the contextual and individual-level factors that may result in inadequate attention to smoking among patients with cancer in the post diagnosis setting, the investigators concluded.

This study was supported by grants from the United States Public Health Service. The costs of publication were defrayed in part by the payment of page charges. The authors reported having no disclosures.

Men who continue smoking after a cancer diagnosis have significantly greater risk of death from any cause than did those who quit smoking at the time of diagnosis, according to findings from the prospective population-based Shanghai Cohort Study.

Of 1,632 men from that ongoing study who developed cancer after enrollment and who were eligible for the current analysis, 931 died during 25 years of follow-up, and 747 of those who died were smokers at the time of their cancer diagnosis. Of these smokers, 214 (29%) quit at the time of diagnosis, 197 (26%) smoked persistently after diagnosis, and 336 (45%) smoked intermittently after diagnosis.

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After the researchers adjusted for age at diagnosis, education, cumulative number of pack-years of prediagnosis smoking, cancer site, and treatment modalities, the risk of death was 76% greater in those who smoked persistently or intermittently after diagnosis, compared with those who quit at diagnosis, reported Dr. Li Tao of the Cancer Prevention Institute of California, Fremont, and her colleagues.

Median survival was 2.1 years after diagnosis for those who continued smoking, compared with 4.4 years for those who quit, the investigators said.

Using a time-dependent approach, and including all patients with cancer, the overall risk of mortality was 59% greater for smokers vs. nonsmokers after cancer diagnosis.

"When analyzed separately for cancer specific patients, the multivariate-adjusted hazard ratios of death for smoking relative to nonsmoking after cancer diagnosis were 1.92 for patients with lung cancer, 1.76 for patients with stomach cancer, 1.65 for patients with colorectal cancer, and 3.66 for patients with bladder cancer," the investigators wrote.

In a similar analysis that included only current smokers at cancer diagnosis, smoking after cancer diagnosis was associated with a 79% increase risk of death relative to nonsmoking after diagnosis for all patients.

"Among cancer-specific patients, the [hazard ratios] of death for smoking vs. nonsmoking after cancer diagnosis were 2.36 in patients with lung cancer, 1.63 in patients with stomach cancer, 2.31 in patients with colorectal cancer, 2.95 in patients with bladder cancer, 2.27 in patients with prostate cancer, and 1.34 in all other patient with cancer," the investigators said (Cancer Epidemiol. Biomarkers Prev. 2013;22:2404-11).

The Shanghai Cohort Study is investigating the association between lifestyle characteristics and cancer development in more than 18,000 middle-age or older men who were enrolled between Jan.1, 1986, and Sept. 30, 1989. Smoking status is ascertained via annual in-person interviews. Patients in the current analysis had a mean age of 68.8 years and were followed for a mean of 5.3 years after cancer diagnosis. They had a median survival time of 5.4 years after diagnosis.

The findings provide new information about smoking and cancer survival, the investigators said, noting that cancer is the leading cause of death among men in China, and the second leading cause of death among men in the United States.

Tobacco use is the most important recognized cause of cancer-related death, they said, adding that strong evidence demonstrates an association between smoking and cancer risk, and between improved health and smoking cessation.

The impact of smoking after a cancer diagnosis, however, has not been well studied, and existing data are conflicting, they noted.

The findings of the present study, which have important public health implications for cancer survivors, health care providers, and policy makers, underscore the importance of smoking cessation interventions – and the potential benefit of cessation on survival – in patients who are diagnosed with cancer, they said.

Although patients diagnosed with cancer are expected to "show great interest and motivation to quit smoking," many face physical, psychological, and social stress that impedes their ability to do so. Furthermore, only about 50% of smokers diagnosed with cancer in the United States receive formal smoking cessation counseling at diagnosis, during treatment, or during follow-up visits, they noted.

"Therefore, there is noticeable room for the improvement of self-managed or health care provider–assisted smoking cessation in the clinical setting of patients with cancer," they wrote, also noting that the message about inferior survival among those who continue smoking after a cancer diagnosis should be conveyed to patients and their families, and should be included in guidelines and evidence-based clinical practices.

This study has considerable strengths – such as knowledge of baseline smoking status and the prospective design. It also has limitations, including limited treatment data and inclusion of only patients who survived 1 or more years after cancer diagnosis.

Nonetheless, the findings provide strong support for smoking cessation intervention programs that target cancer survivors and should inform future research into the contextual and individual-level factors that may result in inadequate attention to smoking among patients with cancer in the post diagnosis setting, the investigators concluded.

This study was supported by grants from the United States Public Health Service. The costs of publication were defrayed in part by the payment of page charges. The authors reported having no disclosures.

ORLANDO – Early skin-to-skin contact between mothers and their newborns was associated with higher rates of exclusive breastfeeding in a retrospective study presented at the annual meeting of the American Academy of Pediatrics.

Of the 150 mothers included in the study, 72% intended to breastfeed exclusively, but only 28% did so. After adjustment for maternal age, mode of delivery, parity, and gestational age, the only factor significantly associated with exclusive breastfeeding other than intention to breastfeed exclusively was early skin-to-skin contact (odds ratio, 3.7), which occurred in 53% of cases, Dr. Darshna Bhatt of Cohen Children’s Medical Center of New York, New Hyde Park, reported.

For the study, Dr. Bhatt and her colleagues reviewed electronic medical records of consecutive admissions to the well baby nursery, including only singleton, late preterm, or term newborns whose records contained documentation regarding whether the newborn had early skin-to-skin contact with the mother. Early skin-to-skin contact is generally defined as mother-baby bare skin contact for a period of time right after delivery; exclusive breastfeeding was defined as receipt of no formula feedings during the hospital stay.

Early skin-to-skin contact between mother and infant in the delivery room has previously been shown to be associated with breastfeeding success, but not all newborns receive skin-to-skin contact in the critical postbirth period, Dr. Bhatt noted. The current findings suggest that promoting skin-to-skin contact in the delivery room may improve exclusive breastfeeding rates, she concluded.

Indeed, during a plenary session at the conference, Dr. Jae Kim, associate professor of pediatrics at the University of California, San Diego (UCSD), said that skin-to-skin contact promotes breastfeeding and provides a "rich experience in the first few minutes of life."

The benefits during this "early golden hour" are believed to be at least threefold, providing physical interaction that regulates the baby’s temperature and provides sensory stimuli; promoting an early breastfeeding response with access to colostrum, which improves both short- and long-term breastfeeding; and allowing for emotional bonding, which is difficult to measure but is "very, very critical to early infant development," he said.

Data suggest that this contact promotes body temperature regulation and physiological stability in the baby with respect to heart rate, breathing response, blood pressure, and blood sugar levels. It also is associated with less crying and a better breastfeeding response, Dr. Kim said, noting that a Cochrane review showed improved breastfeeding at 1 and 4 months, with trends toward longer duration of breastfeeding overall, in healthy term infants who experience early skin-to-skin contact. Improvement in terms of cardiorespiratory stability and blood glucose control also was seen in late pre-term infants.

Although better data – particularly on long-term effects – are needed, it is clear that skin-to-skin contact can "dramatically improve the breastfeeding success rate, halve the time to actually start breastfeeding, improve the satisfaction of both the mother and the family, and also [lead to] an increased amount of exclusive breastfeeding in those babies," he said.

Many hospitals, including his own institution, have moved toward a model that promotes early skin-to-skin contact, he said, adding that most babies at UCSD are coupled with their mother for early skin-to-skin contact.

The incidence of early skin-to-skin contact and establishment of breastfeeding at UCSD is very high for normal vaginal-birth babies and normal cesarean-section babies.

"We as pediatricians play an incredible role in really affecting this change. It’s not just the medical nurses that deliver this care, but it’s about the physicians sending a strong message about how important it is," he said, noting that the pediatricians at his hospital "make a very special point" to get babies back to their moms immediately after the physical examination and to emphasize the importance of skin-to-skin time.

Skin-to-skin contact can also be promoted in the neonatal intensive care unit (NICU), he said.

Data suggest that preterm and low-birth-weight infants do dramatically better with skin-to-skin contact, with improvements in mortality, sepsis, hypothermia, growth, mother-infant attachment, motor development, long-term cognitive development, stress and pain response, colic, sleep response, pain, breastfeeding, and length of stay.

This is an excellent model in limited-resource settings, and benefits have also been seen at UCSD.

"I think we can make a very strong case right now, especially in a family-centered model, the NICU, that we should be pushing for more and more skin-to-skin [contact time]," he said, noting that parents should be encouraged to request daily skin-to-skin therapy in the NICU.

A program at UCSD – the SPIN (Supporting Preterm Infant Nutrition) Program, which was designed to promote better preterm infant nutrition – has harnessed the benefits of early skin-to-skin contact and early human milk intake to move this approach from a regional program to a national platform, "where we can standardize how we deal with preterm infants and their nutrition," he said. Dialogue is encouraged to help improve standardization across the country, he said.

How can such a program be implemented?

It’s important to standardize the practice by gathering key stakeholders and empowering them to target certain objectives, take one step at a time, and develop a broad-based education program to teach everyone how to achieve the objectives. This is important for something like skin-to-skin contact, which involves the efforts of staff from many different areas (nurses from nursery, labor and delivery, NICU, etc.).

In addition, for quality improvement it is important to have some measure of the benchmarks you are targeting in order to measure success.

"A lot of the time, it’s just about getting everyone to the same table, having the same talk, and realizing the information is not that complicated, and that the practice is actually relatively easy to implement, even when it comes to very vulnerable babies in the NICU," he said.

Dr. Bhatt reported having no disclosures. Dr. Kim is on the speaker’s bureaus for Nestle Nutrition, Nutricia, Abbott Nutrition, and Medela, and has received honoraria or research grant support from Medela and GE Healthcare.

ORLANDO – Early skin-to-skin contact between mothers and their newborns was associated with higher rates of exclusive breastfeeding in a retrospective study presented at the annual meeting of the American Academy of Pediatrics.

Of the 150 mothers included in the study, 72% intended to breastfeed exclusively, but only 28% did so. After adjustment for maternal age, mode of delivery, parity, and gestational age, the only factor significantly associated with exclusive breastfeeding other than intention to breastfeed exclusively was early skin-to-skin contact (odds ratio, 3.7), which occurred in 53% of cases, Dr. Darshna Bhatt of Cohen Children’s Medical Center of New York, New Hyde Park, reported.

For the study, Dr. Bhatt and her colleagues reviewed electronic medical records of consecutive admissions to the well baby nursery, including only singleton, late preterm, or term newborns whose records contained documentation regarding whether the newborn had early skin-to-skin contact with the mother. Early skin-to-skin contact is generally defined as mother-baby bare skin contact for a period of time right after delivery; exclusive breastfeeding was defined as receipt of no formula feedings during the hospital stay.

Early skin-to-skin contact between mother and infant in the delivery room has previously been shown to be associated with breastfeeding success, but not all newborns receive skin-to-skin contact in the critical postbirth period, Dr. Bhatt noted. The current findings suggest that promoting skin-to-skin contact in the delivery room may improve exclusive breastfeeding rates, she concluded.

Indeed, during a plenary session at the conference, Dr. Jae Kim, associate professor of pediatrics at the University of California, San Diego (UCSD), said that skin-to-skin contact promotes breastfeeding and provides a "rich experience in the first few minutes of life."

The benefits during this "early golden hour" are believed to be at least threefold, providing physical interaction that regulates the baby’s temperature and provides sensory stimuli; promoting an early breastfeeding response with access to colostrum, which improves both short- and long-term breastfeeding; and allowing for emotional bonding, which is difficult to measure but is "very, very critical to early infant development," he said.

Data suggest that this contact promotes body temperature regulation and physiological stability in the baby with respect to heart rate, breathing response, blood pressure, and blood sugar levels. It also is associated with less crying and a better breastfeeding response, Dr. Kim said, noting that a Cochrane review showed improved breastfeeding at 1 and 4 months, with trends toward longer duration of breastfeeding overall, in healthy term infants who experience early skin-to-skin contact. Improvement in terms of cardiorespiratory stability and blood glucose control also was seen in late pre-term infants.

Although better data – particularly on long-term effects – are needed, it is clear that skin-to-skin contact can "dramatically improve the breastfeeding success rate, halve the time to actually start breastfeeding, improve the satisfaction of both the mother and the family, and also [lead to] an increased amount of exclusive breastfeeding in those babies," he said.

Many hospitals, including his own institution, have moved toward a model that promotes early skin-to-skin contact, he said, adding that most babies at UCSD are coupled with their mother for early skin-to-skin contact.

The incidence of early skin-to-skin contact and establishment of breastfeeding at UCSD is very high for normal vaginal-birth babies and normal cesarean-section babies.

"We as pediatricians play an incredible role in really affecting this change. It’s not just the medical nurses that deliver this care, but it’s about the physicians sending a strong message about how important it is," he said, noting that the pediatricians at his hospital "make a very special point" to get babies back to their moms immediately after the physical examination and to emphasize the importance of skin-to-skin time.

Skin-to-skin contact can also be promoted in the neonatal intensive care unit (NICU), he said.

Data suggest that preterm and low-birth-weight infants do dramatically better with skin-to-skin contact, with improvements in mortality, sepsis, hypothermia, growth, mother-infant attachment, motor development, long-term cognitive development, stress and pain response, colic, sleep response, pain, breastfeeding, and length of stay.

This is an excellent model in limited-resource settings, and benefits have also been seen at UCSD.

"I think we can make a very strong case right now, especially in a family-centered model, the NICU, that we should be pushing for more and more skin-to-skin [contact time]," he said, noting that parents should be encouraged to request daily skin-to-skin therapy in the NICU.

A program at UCSD – the SPIN (Supporting Preterm Infant Nutrition) Program, which was designed to promote better preterm infant nutrition – has harnessed the benefits of early skin-to-skin contact and early human milk intake to move this approach from a regional program to a national platform, "where we can standardize how we deal with preterm infants and their nutrition," he said. Dialogue is encouraged to help improve standardization across the country, he said.

How can such a program be implemented?

It’s important to standardize the practice by gathering key stakeholders and empowering them to target certain objectives, take one step at a time, and develop a broad-based education program to teach everyone how to achieve the objectives. This is important for something like skin-to-skin contact, which involves the efforts of staff from many different areas (nurses from nursery, labor and delivery, NICU, etc.).

In addition, for quality improvement it is important to have some measure of the benchmarks you are targeting in order to measure success.

"A lot of the time, it’s just about getting everyone to the same table, having the same talk, and realizing the information is not that complicated, and that the practice is actually relatively easy to implement, even when it comes to very vulnerable babies in the NICU," he said.

Dr. Bhatt reported having no disclosures. Dr. Kim is on the speaker’s bureaus for Nestle Nutrition, Nutricia, Abbott Nutrition, and Medela, and has received honoraria or research grant support from Medela and GE Healthcare.

ORLANDO – Early skin-to-skin contact between mothers and their newborns was associated with higher rates of exclusive breastfeeding in a retrospective study presented at the annual meeting of the American Academy of Pediatrics.

Of the 150 mothers included in the study, 72% intended to breastfeed exclusively, but only 28% did so. After adjustment for maternal age, mode of delivery, parity, and gestational age, the only factor significantly associated with exclusive breastfeeding other than intention to breastfeed exclusively was early skin-to-skin contact (odds ratio, 3.7), which occurred in 53% of cases, Dr. Darshna Bhatt of Cohen Children’s Medical Center of New York, New Hyde Park, reported.

For the study, Dr. Bhatt and her colleagues reviewed electronic medical records of consecutive admissions to the well baby nursery, including only singleton, late preterm, or term newborns whose records contained documentation regarding whether the newborn had early skin-to-skin contact with the mother. Early skin-to-skin contact is generally defined as mother-baby bare skin contact for a period of time right after delivery; exclusive breastfeeding was defined as receipt of no formula feedings during the hospital stay.

Early skin-to-skin contact between mother and infant in the delivery room has previously been shown to be associated with breastfeeding success, but not all newborns receive skin-to-skin contact in the critical postbirth period, Dr. Bhatt noted. The current findings suggest that promoting skin-to-skin contact in the delivery room may improve exclusive breastfeeding rates, she concluded.

Indeed, during a plenary session at the conference, Dr. Jae Kim, associate professor of pediatrics at the University of California, San Diego (UCSD), said that skin-to-skin contact promotes breastfeeding and provides a "rich experience in the first few minutes of life."

The benefits during this "early golden hour" are believed to be at least threefold, providing physical interaction that regulates the baby’s temperature and provides sensory stimuli; promoting an early breastfeeding response with access to colostrum, which improves both short- and long-term breastfeeding; and allowing for emotional bonding, which is difficult to measure but is "very, very critical to early infant development," he said.

Data suggest that this contact promotes body temperature regulation and physiological stability in the baby with respect to heart rate, breathing response, blood pressure, and blood sugar levels. It also is associated with less crying and a better breastfeeding response, Dr. Kim said, noting that a Cochrane review showed improved breastfeeding at 1 and 4 months, with trends toward longer duration of breastfeeding overall, in healthy term infants who experience early skin-to-skin contact. Improvement in terms of cardiorespiratory stability and blood glucose control also was seen in late pre-term infants.

Although better data – particularly on long-term effects – are needed, it is clear that skin-to-skin contact can "dramatically improve the breastfeeding success rate, halve the time to actually start breastfeeding, improve the satisfaction of both the mother and the family, and also [lead to] an increased amount of exclusive breastfeeding in those babies," he said.

Many hospitals, including his own institution, have moved toward a model that promotes early skin-to-skin contact, he said, adding that most babies at UCSD are coupled with their mother for early skin-to-skin contact.

The incidence of early skin-to-skin contact and establishment of breastfeeding at UCSD is very high for normal vaginal-birth babies and normal cesarean-section babies.

"We as pediatricians play an incredible role in really affecting this change. It’s not just the medical nurses that deliver this care, but it’s about the physicians sending a strong message about how important it is," he said, noting that the pediatricians at his hospital "make a very special point" to get babies back to their moms immediately after the physical examination and to emphasize the importance of skin-to-skin time.

Skin-to-skin contact can also be promoted in the neonatal intensive care unit (NICU), he said.

Data suggest that preterm and low-birth-weight infants do dramatically better with skin-to-skin contact, with improvements in mortality, sepsis, hypothermia, growth, mother-infant attachment, motor development, long-term cognitive development, stress and pain response, colic, sleep response, pain, breastfeeding, and length of stay.

This is an excellent model in limited-resource settings, and benefits have also been seen at UCSD.

"I think we can make a very strong case right now, especially in a family-centered model, the NICU, that we should be pushing for more and more skin-to-skin [contact time]," he said, noting that parents should be encouraged to request daily skin-to-skin therapy in the NICU.

A program at UCSD – the SPIN (Supporting Preterm Infant Nutrition) Program, which was designed to promote better preterm infant nutrition – has harnessed the benefits of early skin-to-skin contact and early human milk intake to move this approach from a regional program to a national platform, "where we can standardize how we deal with preterm infants and their nutrition," he said. Dialogue is encouraged to help improve standardization across the country, he said.

How can such a program be implemented?

It’s important to standardize the practice by gathering key stakeholders and empowering them to target certain objectives, take one step at a time, and develop a broad-based education program to teach everyone how to achieve the objectives. This is important for something like skin-to-skin contact, which involves the efforts of staff from many different areas (nurses from nursery, labor and delivery, NICU, etc.).

In addition, for quality improvement it is important to have some measure of the benchmarks you are targeting in order to measure success.

"A lot of the time, it’s just about getting everyone to the same table, having the same talk, and realizing the information is not that complicated, and that the practice is actually relatively easy to implement, even when it comes to very vulnerable babies in the NICU," he said.

Dr. Bhatt reported having no disclosures. Dr. Kim is on the speaker’s bureaus for Nestle Nutrition, Nutricia, Abbott Nutrition, and Medela, and has received honoraria or research grant support from Medela and GE Healthcare.

Many areas of the United States have few or no practicing adult rheumatologists, and in some cases – particularly in smaller "micropolitan" areas – the closest practicing rheumatologist is 200 miles away, according to an analysis of U.S. Census data and information from the American College of Rheumatology membership database.

Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care, reported Dr. John D. FitzGerald of the University of California, Los Angeles, and his colleagues. The authors are members of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues.

These findings come in the wake of an American College of Rheumatology workforce study initiated in 2005, which showed that demand for rheumatologic care at that time was in balance with the supply of adult rheumatologists (with an estimated 1.67 rheumatologists per 100,000 persons), but which predicted that demand would outstrip supply over time, leading to a shortage of 2,500 adult rheumatologists by 2025. The ACR responded to that report by increasing funding for the training of new rheumatologists by targeting programs with unfilled Accreditation Council for Graduate Medical Education slots, the investigators said.

They noted, however, that the national estimates did not consider regional variation in the distribution of rheumatologists. "Clustering of rheumatologists in some regions can leave other areas of the country with too few adult rheumatologists in supply," wrote Dr. FitzGerald and his associates, who mapped all adult practicing rheumatologists’ addresses as recorded in the 2010 ACR membership database, and assessed the number of rheumatologists in Core Based Statistical Areas (CBSAs), commonly referred to as micropolitan and metropolitan areas. CBSAs are "defined by regions with a high degree of social and economic integration (determined by commute to work) around a central urban core," they said.

The findings of the current study demonstrate that regional shortages already exist. "If we simply use the 1.67 number of rheumatologists per 100,000 persons as a definition of insufficient rheumatology supply, then a majority (85%) of the CBSAs would be potentially underserved," the investigators noted.

When a definition of no practicing rheumatologists within a 50-mile travel distance is used, 24% of CBSAs – representing 18.9 million persons – would still be affected by an insufficient supply of rheumatologists; with a 100-mile cut point, 5% of CBSAs –representing 2.5 million people – would be underserved.

"While this is no surprise to affected local patients, practitioners, or policy makers, this study identifies potential target communities ... that might benefit most from addition of a local rheumatologist," the investigators noted.

One possible intervention for addressing the shortage is simply providing up-to-date information about shortages, as this could lead to migration, expansion of existing practices, or attraction of new rheumatologists. Increasing the supply of trainees in areas with unmet needs and committing additional funds to training programs in underserved areas are also possible interventions, the authors said.

Approaches such as the use of traveling clinics and e-mail or video consultation, which have previously been used to address shortages in rural areas, could also be helpful, they said, adding that it has been suggested that midlevel providers could also effectively help fill workforce shortages.

According to the ACR database, there were 3,920 practicing adult rheumatologists in 2010; 90% practiced in metropolitan areas (areas with at least 50,000 population around a central urban core), 3% practiced in micropolitan areas (areas with 10,000 to less than 50,000 population, excluding rare exceptions centered around a less dense urban cluster), and 7% practiced in rural regions.

"Notably, a greater proportion of rheumatologists were practicing in metropolitan areas (over micropolitan areas) than would be expected based on population distribution alone. While only 31 metropolitan areas (9%) did not have a practicing member rheumatologist, the majority of micropolitan areas (84%) did not have a rheumatologist," the investigators wrote.

As for areas with no rheumatologist, the distances to the nearest practicing rheumatologist varied widely. Only 1% of metropolitan areas, compared with 16% of micropolitan areas, had a distance of more than 75 miles to the nearest rheumatologist, and CBSAs with populations over 200,000 had a travel distance as great as 94 miles, while some smaller micropolitan regions had travel distances greater than 200 miles, for example.

Many smaller micropolitan areas with populations of at least 40,000 had no practicing rheumatologists, and several more populous areas with populations of 200,000 or more also had no practicing rheumatologist.

Conversely, areas with higher population densities; greater proportions of younger, female, white, and Asian populations; and the presence of an active adult fellowship training program had greater numbers of rheumatologists (Arthritis Rheum. 2013 Nov. 27 [doi:10.1002/art.38167]).

For 360 metropolitan areas where median household income data were available, higher income was associated with a greater number of rheumatologists.

This study is limited by the fact that not all practicing rheumatologists are registered with the ACR, and by the inability to account for practice type (such as part time, mixed internal medicine/rheumatology panels, and multisite practices); an assumption of uniform demand across populations; and a lack of consideration of competing sources of care (such as internists, family practitioners, and midlevel providers), the investigators noted.

Better information is needed regarding factors that affect access to rheumatologists in underserved areas, and until this information becomes available, the current findings should be considered preliminary and exploratory, they said.

"More comprehensive practice databases and additional research [are] needed prior to policy implementation or reallocation of current resources. However, the present report identifies ongoing regional shortages in the rheumatology workforce, and highlights potential target communities that might benefit most from addition of a local rheumatologist," they wrote.

The authors reported having no relevant financial conflicts of interest. One author, David A. Elashoff, Ph.D., was supported by a National Institutes of Health/National Center for Advancing Translational Science UCLA CTSI grant.

Many areas of the United States have few or no practicing adult rheumatologists, and in some cases – particularly in smaller "micropolitan" areas – the closest practicing rheumatologist is 200 miles away, according to an analysis of U.S. Census data and information from the American College of Rheumatology membership database.

Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care, reported Dr. John D. FitzGerald of the University of California, Los Angeles, and his colleagues. The authors are members of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues.

These findings come in the wake of an American College of Rheumatology workforce study initiated in 2005, which showed that demand for rheumatologic care at that time was in balance with the supply of adult rheumatologists (with an estimated 1.67 rheumatologists per 100,000 persons), but which predicted that demand would outstrip supply over time, leading to a shortage of 2,500 adult rheumatologists by 2025. The ACR responded to that report by increasing funding for the training of new rheumatologists by targeting programs with unfilled Accreditation Council for Graduate Medical Education slots, the investigators said.

They noted, however, that the national estimates did not consider regional variation in the distribution of rheumatologists. "Clustering of rheumatologists in some regions can leave other areas of the country with too few adult rheumatologists in supply," wrote Dr. FitzGerald and his associates, who mapped all adult practicing rheumatologists’ addresses as recorded in the 2010 ACR membership database, and assessed the number of rheumatologists in Core Based Statistical Areas (CBSAs), commonly referred to as micropolitan and metropolitan areas. CBSAs are "defined by regions with a high degree of social and economic integration (determined by commute to work) around a central urban core," they said.

The findings of the current study demonstrate that regional shortages already exist. "If we simply use the 1.67 number of rheumatologists per 100,000 persons as a definition of insufficient rheumatology supply, then a majority (85%) of the CBSAs would be potentially underserved," the investigators noted.

When a definition of no practicing rheumatologists within a 50-mile travel distance is used, 24% of CBSAs – representing 18.9 million persons – would still be affected by an insufficient supply of rheumatologists; with a 100-mile cut point, 5% of CBSAs –representing 2.5 million people – would be underserved.

"While this is no surprise to affected local patients, practitioners, or policy makers, this study identifies potential target communities ... that might benefit most from addition of a local rheumatologist," the investigators noted.

One possible intervention for addressing the shortage is simply providing up-to-date information about shortages, as this could lead to migration, expansion of existing practices, or attraction of new rheumatologists. Increasing the supply of trainees in areas with unmet needs and committing additional funds to training programs in underserved areas are also possible interventions, the authors said.

Approaches such as the use of traveling clinics and e-mail or video consultation, which have previously been used to address shortages in rural areas, could also be helpful, they said, adding that it has been suggested that midlevel providers could also effectively help fill workforce shortages.

According to the ACR database, there were 3,920 practicing adult rheumatologists in 2010; 90% practiced in metropolitan areas (areas with at least 50,000 population around a central urban core), 3% practiced in micropolitan areas (areas with 10,000 to less than 50,000 population, excluding rare exceptions centered around a less dense urban cluster), and 7% practiced in rural regions.

"Notably, a greater proportion of rheumatologists were practicing in metropolitan areas (over micropolitan areas) than would be expected based on population distribution alone. While only 31 metropolitan areas (9%) did not have a practicing member rheumatologist, the majority of micropolitan areas (84%) did not have a rheumatologist," the investigators wrote.

As for areas with no rheumatologist, the distances to the nearest practicing rheumatologist varied widely. Only 1% of metropolitan areas, compared with 16% of micropolitan areas, had a distance of more than 75 miles to the nearest rheumatologist, and CBSAs with populations over 200,000 had a travel distance as great as 94 miles, while some smaller micropolitan regions had travel distances greater than 200 miles, for example.

Many smaller micropolitan areas with populations of at least 40,000 had no practicing rheumatologists, and several more populous areas with populations of 200,000 or more also had no practicing rheumatologist.

Conversely, areas with higher population densities; greater proportions of younger, female, white, and Asian populations; and the presence of an active adult fellowship training program had greater numbers of rheumatologists (Arthritis Rheum. 2013 Nov. 27 [doi:10.1002/art.38167]).

For 360 metropolitan areas where median household income data were available, higher income was associated with a greater number of rheumatologists.

This study is limited by the fact that not all practicing rheumatologists are registered with the ACR, and by the inability to account for practice type (such as part time, mixed internal medicine/rheumatology panels, and multisite practices); an assumption of uniform demand across populations; and a lack of consideration of competing sources of care (such as internists, family practitioners, and midlevel providers), the investigators noted.

Better information is needed regarding factors that affect access to rheumatologists in underserved areas, and until this information becomes available, the current findings should be considered preliminary and exploratory, they said.

"More comprehensive practice databases and additional research [are] needed prior to policy implementation or reallocation of current resources. However, the present report identifies ongoing regional shortages in the rheumatology workforce, and highlights potential target communities that might benefit most from addition of a local rheumatologist," they wrote.

The authors reported having no relevant financial conflicts of interest. One author, David A. Elashoff, Ph.D., was supported by a National Institutes of Health/National Center for Advancing Translational Science UCLA CTSI grant.

Many areas of the United States have few or no practicing adult rheumatologists, and in some cases – particularly in smaller "micropolitan" areas – the closest practicing rheumatologist is 200 miles away, according to an analysis of U.S. Census data and information from the American College of Rheumatology membership database.

Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care, reported Dr. John D. FitzGerald of the University of California, Los Angeles, and his colleagues. The authors are members of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues.

These findings come in the wake of an American College of Rheumatology workforce study initiated in 2005, which showed that demand for rheumatologic care at that time was in balance with the supply of adult rheumatologists (with an estimated 1.67 rheumatologists per 100,000 persons), but which predicted that demand would outstrip supply over time, leading to a shortage of 2,500 adult rheumatologists by 2025. The ACR responded to that report by increasing funding for the training of new rheumatologists by targeting programs with unfilled Accreditation Council for Graduate Medical Education slots, the investigators said.

They noted, however, that the national estimates did not consider regional variation in the distribution of rheumatologists. "Clustering of rheumatologists in some regions can leave other areas of the country with too few adult rheumatologists in supply," wrote Dr. FitzGerald and his associates, who mapped all adult practicing rheumatologists’ addresses as recorded in the 2010 ACR membership database, and assessed the number of rheumatologists in Core Based Statistical Areas (CBSAs), commonly referred to as micropolitan and metropolitan areas. CBSAs are "defined by regions with a high degree of social and economic integration (determined by commute to work) around a central urban core," they said.

The findings of the current study demonstrate that regional shortages already exist. "If we simply use the 1.67 number of rheumatologists per 100,000 persons as a definition of insufficient rheumatology supply, then a majority (85%) of the CBSAs would be potentially underserved," the investigators noted.

When a definition of no practicing rheumatologists within a 50-mile travel distance is used, 24% of CBSAs – representing 18.9 million persons – would still be affected by an insufficient supply of rheumatologists; with a 100-mile cut point, 5% of CBSAs –representing 2.5 million people – would be underserved.

"While this is no surprise to affected local patients, practitioners, or policy makers, this study identifies potential target communities ... that might benefit most from addition of a local rheumatologist," the investigators noted.

One possible intervention for addressing the shortage is simply providing up-to-date information about shortages, as this could lead to migration, expansion of existing practices, or attraction of new rheumatologists. Increasing the supply of trainees in areas with unmet needs and committing additional funds to training programs in underserved areas are also possible interventions, the authors said.

Approaches such as the use of traveling clinics and e-mail or video consultation, which have previously been used to address shortages in rural areas, could also be helpful, they said, adding that it has been suggested that midlevel providers could also effectively help fill workforce shortages.

According to the ACR database, there were 3,920 practicing adult rheumatologists in 2010; 90% practiced in metropolitan areas (areas with at least 50,000 population around a central urban core), 3% practiced in micropolitan areas (areas with 10,000 to less than 50,000 population, excluding rare exceptions centered around a less dense urban cluster), and 7% practiced in rural regions.

"Notably, a greater proportion of rheumatologists were practicing in metropolitan areas (over micropolitan areas) than would be expected based on population distribution alone. While only 31 metropolitan areas (9%) did not have a practicing member rheumatologist, the majority of micropolitan areas (84%) did not have a rheumatologist," the investigators wrote.

As for areas with no rheumatologist, the distances to the nearest practicing rheumatologist varied widely. Only 1% of metropolitan areas, compared with 16% of micropolitan areas, had a distance of more than 75 miles to the nearest rheumatologist, and CBSAs with populations over 200,000 had a travel distance as great as 94 miles, while some smaller micropolitan regions had travel distances greater than 200 miles, for example.

Many smaller micropolitan areas with populations of at least 40,000 had no practicing rheumatologists, and several more populous areas with populations of 200,000 or more also had no practicing rheumatologist.

Conversely, areas with higher population densities; greater proportions of younger, female, white, and Asian populations; and the presence of an active adult fellowship training program had greater numbers of rheumatologists (Arthritis Rheum. 2013 Nov. 27 [doi:10.1002/art.38167]).

For 360 metropolitan areas where median household income data were available, higher income was associated with a greater number of rheumatologists.

This study is limited by the fact that not all practicing rheumatologists are registered with the ACR, and by the inability to account for practice type (such as part time, mixed internal medicine/rheumatology panels, and multisite practices); an assumption of uniform demand across populations; and a lack of consideration of competing sources of care (such as internists, family practitioners, and midlevel providers), the investigators noted.

Better information is needed regarding factors that affect access to rheumatologists in underserved areas, and until this information becomes available, the current findings should be considered preliminary and exploratory, they said.

"More comprehensive practice databases and additional research [are] needed prior to policy implementation or reallocation of current resources. However, the present report identifies ongoing regional shortages in the rheumatology workforce, and highlights potential target communities that might benefit most from addition of a local rheumatologist," they wrote.

The authors reported having no relevant financial conflicts of interest. One author, David A. Elashoff, Ph.D., was supported by a National Institutes of Health/National Center for Advancing Translational Science UCLA CTSI grant.

ATLANTA – Extending the duration of initial prednisolone treatment from 2 months to 6 months while escalating the dose failed to reduce the incidence of frequently relapsing nephrotic syndrome in children in a randomized, open-label, noninferiority trial.

The time to relapse did not differ significantly among 255 children with an initial episode of steroid-sensitive nephrotic syndrome who presented to any of 91 participating hospitals in Japan and who were randomized to receive either 2 or 6 months of initial prednisolone treatment with cumulative doses of 2,240 mg/m² and 3,885 mg/m², respectively, followed by relapse prednisolone treatment per study protocol for a total of 24 months.

At 24 months, the frequently relapsing nephrotic syndrome (FRNS)-free rates were 56.2% and 50.8% in the groups, respectively (hazard ratio, 0.86), Norishige Yoshikawa, Ph.D., reported in a late-breaking poster at Kidney Week 2013.

The hazard ratio met the prespecified noninferiority margin (HR, 1.3), said Dr. Yoshikawa of the department of pediatrics at Wakayama Medical University, Japan.

Furthermore, the groups did not differ with respect to number of relapses: 1.25 per person-year in the 2-month group vs. 1.30 per person-year in the 6-month group, for a relapse rate ratio of 0.94.

The initial approach to treatment in children with FRNS varies considerably, and these findings conflict with those of a 2007 Cochrane Review (Cochrane Database Syst. Rev. 2007;4:CD001533 [doi: 10.1002/14651858.CD001533.pub4]). That review identified 24 related trials that suggested longer duration of prednisone or prednisolone treatment (3 or more months vs. 2 months) reduced the risk of relapse at 12-24 months (risk ratio, 0.70), that there was an inverse linear relationship between treatment duration and risk of relapse (RR, 1.26), and that 6 months (vs. 3 months) of treatment was more effective for reducing the risk of relapse (RR, 0.57).

Although the Cochrane Review authors concluded that children with a first episode of steroid-sensitive nephrotic syndrome should be treated for at least 3 months – and that there appears to be an increase in benefit with up to 7 months of treatment – they also noted that additional well-designed and adequately powered randomized clinical trials were needed to assess the appropriate duration of initial steroid treatment in children with FRNS, Dr. Yoshikawa said.

The meeting was sponsored by the American Society of Nephrology. Dr. Yoshikawa’s study was supported with non–U.S. government funding. Dr. Yoshikawa reported having no disclosures.

ATLANTA – Extending the duration of initial prednisolone treatment from 2 months to 6 months while escalating the dose failed to reduce the incidence of frequently relapsing nephrotic syndrome in children in a randomized, open-label, noninferiority trial.

The time to relapse did not differ significantly among 255 children with an initial episode of steroid-sensitive nephrotic syndrome who presented to any of 91 participating hospitals in Japan and who were randomized to receive either 2 or 6 months of initial prednisolone treatment with cumulative doses of 2,240 mg/m² and 3,885 mg/m², respectively, followed by relapse prednisolone treatment per study protocol for a total of 24 months.

At 24 months, the frequently relapsing nephrotic syndrome (FRNS)-free rates were 56.2% and 50.8% in the groups, respectively (hazard ratio, 0.86), Norishige Yoshikawa, Ph.D., reported in a late-breaking poster at Kidney Week 2013.

The hazard ratio met the prespecified noninferiority margin (HR, 1.3), said Dr. Yoshikawa of the department of pediatrics at Wakayama Medical University, Japan.

Furthermore, the groups did not differ with respect to number of relapses: 1.25 per person-year in the 2-month group vs. 1.30 per person-year in the 6-month group, for a relapse rate ratio of 0.94.

The initial approach to treatment in children with FRNS varies considerably, and these findings conflict with those of a 2007 Cochrane Review (Cochrane Database Syst. Rev. 2007;4:CD001533 [doi: 10.1002/14651858.CD001533.pub4]). That review identified 24 related trials that suggested longer duration of prednisone or prednisolone treatment (3 or more months vs. 2 months) reduced the risk of relapse at 12-24 months (risk ratio, 0.70), that there was an inverse linear relationship between treatment duration and risk of relapse (RR, 1.26), and that 6 months (vs. 3 months) of treatment was more effective for reducing the risk of relapse (RR, 0.57).

Although the Cochrane Review authors concluded that children with a first episode of steroid-sensitive nephrotic syndrome should be treated for at least 3 months – and that there appears to be an increase in benefit with up to 7 months of treatment – they also noted that additional well-designed and adequately powered randomized clinical trials were needed to assess the appropriate duration of initial steroid treatment in children with FRNS, Dr. Yoshikawa said.

The meeting was sponsored by the American Society of Nephrology. Dr. Yoshikawa’s study was supported with non–U.S. government funding. Dr. Yoshikawa reported having no disclosures.

ATLANTA – Extending the duration of initial prednisolone treatment from 2 months to 6 months while escalating the dose failed to reduce the incidence of frequently relapsing nephrotic syndrome in children in a randomized, open-label, noninferiority trial.

The time to relapse did not differ significantly among 255 children with an initial episode of steroid-sensitive nephrotic syndrome who presented to any of 91 participating hospitals in Japan and who were randomized to receive either 2 or 6 months of initial prednisolone treatment with cumulative doses of 2,240 mg/m² and 3,885 mg/m², respectively, followed by relapse prednisolone treatment per study protocol for a total of 24 months.

At 24 months, the frequently relapsing nephrotic syndrome (FRNS)-free rates were 56.2% and 50.8% in the groups, respectively (hazard ratio, 0.86), Norishige Yoshikawa, Ph.D., reported in a late-breaking poster at Kidney Week 2013.

The hazard ratio met the prespecified noninferiority margin (HR, 1.3), said Dr. Yoshikawa of the department of pediatrics at Wakayama Medical University, Japan.

Furthermore, the groups did not differ with respect to number of relapses: 1.25 per person-year in the 2-month group vs. 1.30 per person-year in the 6-month group, for a relapse rate ratio of 0.94.

The initial approach to treatment in children with FRNS varies considerably, and these findings conflict with those of a 2007 Cochrane Review (Cochrane Database Syst. Rev. 2007;4:CD001533 [doi: 10.1002/14651858.CD001533.pub4]). That review identified 24 related trials that suggested longer duration of prednisone or prednisolone treatment (3 or more months vs. 2 months) reduced the risk of relapse at 12-24 months (risk ratio, 0.70), that there was an inverse linear relationship between treatment duration and risk of relapse (RR, 1.26), and that 6 months (vs. 3 months) of treatment was more effective for reducing the risk of relapse (RR, 0.57).

Although the Cochrane Review authors concluded that children with a first episode of steroid-sensitive nephrotic syndrome should be treated for at least 3 months – and that there appears to be an increase in benefit with up to 7 months of treatment – they also noted that additional well-designed and adequately powered randomized clinical trials were needed to assess the appropriate duration of initial steroid treatment in children with FRNS, Dr. Yoshikawa said.

The meeting was sponsored by the American Society of Nephrology. Dr. Yoshikawa’s study was supported with non–U.S. government funding. Dr. Yoshikawa reported having no disclosures.

ORLANDO – A prospective comparison of three brands of football helmets and various types of mouth guards raises questions about manufacturers’ claims regarding protection against sport-related concussions, according to Dr. Alison Brooks.

During the 2012 football season, 115 of 1,332 (9%) football players from 36 high schools had 116 sport-related concussions (SRCs). More than half (52%) of the players wore Riddell helmets, 35% wore Schutt helmets, and 13% wore Xenith helmets. Thirty-nine percent of the helmets were purchased during 2011-2012, 33% during 2009-2010, and 28% during 2002-2008.

No difference was seen in the rate or severity (based on days lost) of sport-related concussion (SRC) by helmet type or helmet purchase year, Dr. Brooks of the University of Wisconsin, Madison, reported at the annual meeting of the American Academy of Pediatrics.

The incidence rates of SRC were 9.5, 8.1, and 6.7 for the Riddell, Schutt, and Xenith helmets, respectively, and the SRC rates by year purchased were 9.3, 7.9, and 8.8 for helmets purchased during 2011-2012, 2009-2010, and 2002-2008, respectively. Median days lost were 13.5, 13.0, and 13.5, respectively.

"Contrary to manufacturer claims, lower risk and severity of SRC were not associated with a specific helmet brand," Dr. Brooks said.

As for mouth guards, 61% of the players wore generic models provided by their school, and 39% wore specialized mouth guards custom fitted by a dental professional or specifically marketed to reduce SRC.

The SRC rate was actually higher for those who wore a specialized (12.7) or custom-fitted (11.3) mouth guard than for those who wore a generic mouth guard (6.4), Dr. Brooks said.

Students included in the study were 9th through 12th graders with a mean age of 15.9 years. The students – who completed a preseason demographic and injury questionnaire (with 171 reporting a concussion in the prior 12 months) – wore various models of the three football helmet brands. Athletic trainers recorded the incidence and severity of SRC throughout the football season.

Although limited by factors such as possible selection bias (as schools and players were aware of the study), and recall bias (with respect to previous concussion status), the findings are important, because about 40,000 SRCs occur in high school football players in the United States each year. Despite limited prospective data on how specific football helmets and mouth guards affect the incidence and severity of SRC, manufacturers often cite laboratory research – based on impact (drop) testing – showing that their brand and/or a specific model will lessen impact forces associated with SRC, and they often claim that players who use their equipment may have a reduced SRC risk, she said, noting that schools and parents may feel pressured to purchase newer, more expensive equipment.

The current findings suggest that caution should be used when considering these claims, Dr. Brooks said.

In an interview, she added, "These preliminary findings are important in helping parents and coaches understand that there is no compelling evidence that any particular helmet or mouth guard significantly reduces concussion risk."

Helmets and mouth guards are nonetheless effective for doing what they are designed to do – prevent skull fractures and intracranial bleeds and dental injuries – and are important pieces of equipment that need to be maintained in good condition, and be fit and worn properly. There is also always a role for trying to improve technology. However, it may not be possible to significantly reduce concussion risk using helmet technology, she said.

"I think focus could be better spent on rule enforcement and coaching education on tackling technique to limit/avoid contact to the head, perhaps limiting contact practices, and behavior change about the intent of tackling to injure or ‘punish’ the opponent," she added.

Dr. Brooks reported having no relevant financial disclosures.

ORLANDO – A prospective comparison of three brands of football helmets and various types of mouth guards raises questions about manufacturers’ claims regarding protection against sport-related concussions, according to Dr. Alison Brooks.

During the 2012 football season, 115 of 1,332 (9%) football players from 36 high schools had 116 sport-related concussions (SRCs). More than half (52%) of the players wore Riddell helmets, 35% wore Schutt helmets, and 13% wore Xenith helmets. Thirty-nine percent of the helmets were purchased during 2011-2012, 33% during 2009-2010, and 28% during 2002-2008.

No difference was seen in the rate or severity (based on days lost) of sport-related concussion (SRC) by helmet type or helmet purchase year, Dr. Brooks of the University of Wisconsin, Madison, reported at the annual meeting of the American Academy of Pediatrics.

The incidence rates of SRC were 9.5, 8.1, and 6.7 for the Riddell, Schutt, and Xenith helmets, respectively, and the SRC rates by year purchased were 9.3, 7.9, and 8.8 for helmets purchased during 2011-2012, 2009-2010, and 2002-2008, respectively. Median days lost were 13.5, 13.0, and 13.5, respectively.

"Contrary to manufacturer claims, lower risk and severity of SRC were not associated with a specific helmet brand," Dr. Brooks said.

As for mouth guards, 61% of the players wore generic models provided by their school, and 39% wore specialized mouth guards custom fitted by a dental professional or specifically marketed to reduce SRC.

The SRC rate was actually higher for those who wore a specialized (12.7) or custom-fitted (11.3) mouth guard than for those who wore a generic mouth guard (6.4), Dr. Brooks said.

Students included in the study were 9th through 12th graders with a mean age of 15.9 years. The students – who completed a preseason demographic and injury questionnaire (with 171 reporting a concussion in the prior 12 months) – wore various models of the three football helmet brands. Athletic trainers recorded the incidence and severity of SRC throughout the football season.

Although limited by factors such as possible selection bias (as schools and players were aware of the study), and recall bias (with respect to previous concussion status), the findings are important, because about 40,000 SRCs occur in high school football players in the United States each year. Despite limited prospective data on how specific football helmets and mouth guards affect the incidence and severity of SRC, manufacturers often cite laboratory research – based on impact (drop) testing – showing that their brand and/or a specific model will lessen impact forces associated with SRC, and they often claim that players who use their equipment may have a reduced SRC risk, she said, noting that schools and parents may feel pressured to purchase newer, more expensive equipment.

The current findings suggest that caution should be used when considering these claims, Dr. Brooks said.

In an interview, she added, "These preliminary findings are important in helping parents and coaches understand that there is no compelling evidence that any particular helmet or mouth guard significantly reduces concussion risk."

Helmets and mouth guards are nonetheless effective for doing what they are designed to do – prevent skull fractures and intracranial bleeds and dental injuries – and are important pieces of equipment that need to be maintained in good condition, and be fit and worn properly. There is also always a role for trying to improve technology. However, it may not be possible to significantly reduce concussion risk using helmet technology, she said.

"I think focus could be better spent on rule enforcement and coaching education on tackling technique to limit/avoid contact to the head, perhaps limiting contact practices, and behavior change about the intent of tackling to injure or ‘punish’ the opponent," she added.

Dr. Brooks reported having no relevant financial disclosures.

ORLANDO – A prospective comparison of three brands of football helmets and various types of mouth guards raises questions about manufacturers’ claims regarding protection against sport-related concussions, according to Dr. Alison Brooks.

During the 2012 football season, 115 of 1,332 (9%) football players from 36 high schools had 116 sport-related concussions (SRCs). More than half (52%) of the players wore Riddell helmets, 35% wore Schutt helmets, and 13% wore Xenith helmets. Thirty-nine percent of the helmets were purchased during 2011-2012, 33% during 2009-2010, and 28% during 2002-2008.

No difference was seen in the rate or severity (based on days lost) of sport-related concussion (SRC) by helmet type or helmet purchase year, Dr. Brooks of the University of Wisconsin, Madison, reported at the annual meeting of the American Academy of Pediatrics.

The incidence rates of SRC were 9.5, 8.1, and 6.7 for the Riddell, Schutt, and Xenith helmets, respectively, and the SRC rates by year purchased were 9.3, 7.9, and 8.8 for helmets purchased during 2011-2012, 2009-2010, and 2002-2008, respectively. Median days lost were 13.5, 13.0, and 13.5, respectively.

"Contrary to manufacturer claims, lower risk and severity of SRC were not associated with a specific helmet brand," Dr. Brooks said.

As for mouth guards, 61% of the players wore generic models provided by their school, and 39% wore specialized mouth guards custom fitted by a dental professional or specifically marketed to reduce SRC.

The SRC rate was actually higher for those who wore a specialized (12.7) or custom-fitted (11.3) mouth guard than for those who wore a generic mouth guard (6.4), Dr. Brooks said.

Students included in the study were 9th through 12th graders with a mean age of 15.9 years. The students – who completed a preseason demographic and injury questionnaire (with 171 reporting a concussion in the prior 12 months) – wore various models of the three football helmet brands. Athletic trainers recorded the incidence and severity of SRC throughout the football season.

Although limited by factors such as possible selection bias (as schools and players were aware of the study), and recall bias (with respect to previous concussion status), the findings are important, because about 40,000 SRCs occur in high school football players in the United States each year. Despite limited prospective data on how specific football helmets and mouth guards affect the incidence and severity of SRC, manufacturers often cite laboratory research – based on impact (drop) testing – showing that their brand and/or a specific model will lessen impact forces associated with SRC, and they often claim that players who use their equipment may have a reduced SRC risk, she said, noting that schools and parents may feel pressured to purchase newer, more expensive equipment.

The current findings suggest that caution should be used when considering these claims, Dr. Brooks said.

In an interview, she added, "These preliminary findings are important in helping parents and coaches understand that there is no compelling evidence that any particular helmet or mouth guard significantly reduces concussion risk."

Helmets and mouth guards are nonetheless effective for doing what they are designed to do – prevent skull fractures and intracranial bleeds and dental injuries – and are important pieces of equipment that need to be maintained in good condition, and be fit and worn properly. There is also always a role for trying to improve technology. However, it may not be possible to significantly reduce concussion risk using helmet technology, she said.

"I think focus could be better spent on rule enforcement and coaching education on tackling technique to limit/avoid contact to the head, perhaps limiting contact practices, and behavior change about the intent of tackling to injure or ‘punish’ the opponent," she added.

Dr. Brooks reported having no relevant financial disclosures.