Doug Brunk

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

A 900-mg daily dose of gabapentin was associated with significant decreases in hot flash severity and frequency, but a 300-mg daily dose of the drug was not, results from a randomized, double-blind, placebo-controlled trial have found.

“We believe gabapentin can be added to the list of nonhormonal agents for the control of hot flashes in women with breast cancer, and the effects of doses higher than 900 mg/day merit further study,” wrote the investigators, led by Kishan J. Pandya, M.D., of the University of Rochester (N.Y.).

In a study funded by the National Cancer Institute, he and his associates randomized 420 women with a mean age of 55 years to receive placebo, 300 mg/day of gabapentin, or 900 mg/day of gabapentin.

The women, the majority of whom were white, were enrolled at 18 different sites of the university's community clinical oncology program. Each of them recorded the severity level of hot flashes and 10 other symptoms experienced in a 1-week self-report diary at baseline and during the fourth and eighth weeks of treatment (Lancet 2005;366:818–24).

Posttreatment analysis revealed that the reduction in hot flash severity score was only 15% for those in the placebo group, compared with 31% for those in the 300 mg/day gabapentin group and 46% for those in the 900 mg/day gabapentin group.

The differences between groups were statistically significant, but only the 900 mg/day dose of gabapentin was associated with significant decreases in hot flash frequency and severity, the investigators said.

No differences were observed among the three treatment groups with respect to the 10 other symptoms, which included fatigue, nausea, and shortness of breath, suggesting that gabapentin was well tolerated.

Gabapentin is approved for the treatment of epileptic seizures. But the medication also is used as a treatment for migraines, restless legs syndrome, and bipolar disorder.

Drug manufacturer Pfizer Inc., which is based in New York City, provided the gabapentin and placebo used in the trial.

A 900-mg daily dose of gabapentin was associated with significant decreases in hot flash severity and frequency, but a 300-mg daily dose of the drug was not, results from a randomized, double-blind, placebo-controlled trial have found.

“We believe gabapentin can be added to the list of nonhormonal agents for the control of hot flashes in women with breast cancer, and the effects of doses higher than 900 mg/day merit further study,” wrote the investigators, led by Kishan J. Pandya, M.D., of the University of Rochester (N.Y.).

In a study funded by the National Cancer Institute, he and his associates randomized 420 women with a mean age of 55 years to receive placebo, 300 mg/day of gabapentin, or 900 mg/day of gabapentin.

The women, the majority of whom were white, were enrolled at 18 different sites of the university's community clinical oncology program. Each of them recorded the severity level of hot flashes and 10 other symptoms experienced in a 1-week self-report diary at baseline and during the fourth and eighth weeks of treatment (Lancet 2005;366:818–24).

Posttreatment analysis revealed that the reduction in hot flash severity score was only 15% for those in the placebo group, compared with 31% for those in the 300 mg/day gabapentin group and 46% for those in the 900 mg/day gabapentin group.

The differences between groups were statistically significant, but only the 900 mg/day dose of gabapentin was associated with significant decreases in hot flash frequency and severity, the investigators said.

No differences were observed among the three treatment groups with respect to the 10 other symptoms, which included fatigue, nausea, and shortness of breath, suggesting that gabapentin was well tolerated.

Gabapentin is approved for the treatment of epileptic seizures. But the medication also is used as a treatment for migraines, restless legs syndrome, and bipolar disorder.

Drug manufacturer Pfizer Inc., which is based in New York City, provided the gabapentin and placebo used in the trial.

A 900-mg daily dose of gabapentin was associated with significant decreases in hot flash severity and frequency, but a 300-mg daily dose of the drug was not, results from a randomized, double-blind, placebo-controlled trial have found.

“We believe gabapentin can be added to the list of nonhormonal agents for the control of hot flashes in women with breast cancer, and the effects of doses higher than 900 mg/day merit further study,” wrote the investigators, led by Kishan J. Pandya, M.D., of the University of Rochester (N.Y.).

In a study funded by the National Cancer Institute, he and his associates randomized 420 women with a mean age of 55 years to receive placebo, 300 mg/day of gabapentin, or 900 mg/day of gabapentin.

The women, the majority of whom were white, were enrolled at 18 different sites of the university's community clinical oncology program. Each of them recorded the severity level of hot flashes and 10 other symptoms experienced in a 1-week self-report diary at baseline and during the fourth and eighth weeks of treatment (Lancet 2005;366:818–24).

Posttreatment analysis revealed that the reduction in hot flash severity score was only 15% for those in the placebo group, compared with 31% for those in the 300 mg/day gabapentin group and 46% for those in the 900 mg/day gabapentin group.

The differences between groups were statistically significant, but only the 900 mg/day dose of gabapentin was associated with significant decreases in hot flash frequency and severity, the investigators said.

No differences were observed among the three treatment groups with respect to the 10 other symptoms, which included fatigue, nausea, and shortness of breath, suggesting that gabapentin was well tolerated.

Gabapentin is approved for the treatment of epileptic seizures. But the medication also is used as a treatment for migraines, restless legs syndrome, and bipolar disorder.

Drug manufacturer Pfizer Inc., which is based in New York City, provided the gabapentin and placebo used in the trial.

SAN DIEGO — Using intravesical anesthetic treatment and pentosan polysulfate to treat chronic pelvic pain was linked to a significant improvement in symptoms 9 weeks after bladder rescue therapy, a study of 47 women has shown.

The finding “clearly demonstrates that treating the bladder component of pelvic pain can result in significant improvement of symptoms,” Jackie Shriver, a certified registered nurse practitioner with the Lima, Ohio-based Midwest Center for Chronic Pelvic Pain and Bladder Control reported at an international congress of the Society of Laparoendoscopic Surgeons.

In a study led by the center's director, Maurice K. Chung, M.D., investigators conducted a prospective analysis of 47 women aged 21–74 who had a diagnosis of chronic pelvic pain and gynecologic-related symptoms for 6 months. At the initial visit, the women filled out questionnaires that included the Pelvic Pain and Urgency/Frequency (PUF) scale, the American Urological Association (AUA) score, and the Interstitial Cystitis Symptomatology Index (ICSI) score.

Six weeks later, all women underwent potassium sensitivity testing (PST) in the office and filled out the same questionnaires. Of the 47 women, 41 (87%) tested positive on the PST.

The women then underwent intravesical anesthetic treatment and pentosan polysulfate therapy for 9 weeks and filled out the same three questionnaires at the end of treatment.

Intravesical therapy was a solution of 10-cc lidocaine 1%, 10-cc bupivacaine 0.5%, 5-cc sodium bicarbonate, and 40,000-U/4-cc heparin, given biweekly for 3 weeks and then weekly for 6 weeks.

The dosage of pentosan polysulfate therapy was 200 mg b.i.d.

The average baseline scores were 14.8 for the PUF, 13.1 for the AUA, and 8.4 for the ICSI. The 6-week rescreening scores were similar: 15.2 for the PUF, 13 for the AUA, and 8.5 for the ICSI.

However, 9 weeks after bladder rescue therapy, the average scores were 11.1 for the PUF, 9.4 for the AUA, and 5.8 for the ICSI. This demonstrated “significant improvement in symptoms,” Ms. Shriver said.

In an interview, Dr. Chung said wide adoption of this approach could reduce the number of hysterectomies performed in the United States each year. He estimated that 10%–20% of hysterectomies result from a diagnosis of chronic pelvic pain.

The study received an honorable mention by the meeting organizers.

SAN DIEGO — Using intravesical anesthetic treatment and pentosan polysulfate to treat chronic pelvic pain was linked to a significant improvement in symptoms 9 weeks after bladder rescue therapy, a study of 47 women has shown.

The finding “clearly demonstrates that treating the bladder component of pelvic pain can result in significant improvement of symptoms,” Jackie Shriver, a certified registered nurse practitioner with the Lima, Ohio-based Midwest Center for Chronic Pelvic Pain and Bladder Control reported at an international congress of the Society of Laparoendoscopic Surgeons.

In a study led by the center's director, Maurice K. Chung, M.D., investigators conducted a prospective analysis of 47 women aged 21–74 who had a diagnosis of chronic pelvic pain and gynecologic-related symptoms for 6 months. At the initial visit, the women filled out questionnaires that included the Pelvic Pain and Urgency/Frequency (PUF) scale, the American Urological Association (AUA) score, and the Interstitial Cystitis Symptomatology Index (ICSI) score.

Six weeks later, all women underwent potassium sensitivity testing (PST) in the office and filled out the same questionnaires. Of the 47 women, 41 (87%) tested positive on the PST.

The women then underwent intravesical anesthetic treatment and pentosan polysulfate therapy for 9 weeks and filled out the same three questionnaires at the end of treatment.

Intravesical therapy was a solution of 10-cc lidocaine 1%, 10-cc bupivacaine 0.5%, 5-cc sodium bicarbonate, and 40,000-U/4-cc heparin, given biweekly for 3 weeks and then weekly for 6 weeks.

The dosage of pentosan polysulfate therapy was 200 mg b.i.d.

The average baseline scores were 14.8 for the PUF, 13.1 for the AUA, and 8.4 for the ICSI. The 6-week rescreening scores were similar: 15.2 for the PUF, 13 for the AUA, and 8.5 for the ICSI.

However, 9 weeks after bladder rescue therapy, the average scores were 11.1 for the PUF, 9.4 for the AUA, and 5.8 for the ICSI. This demonstrated “significant improvement in symptoms,” Ms. Shriver said.

In an interview, Dr. Chung said wide adoption of this approach could reduce the number of hysterectomies performed in the United States each year. He estimated that 10%–20% of hysterectomies result from a diagnosis of chronic pelvic pain.

The study received an honorable mention by the meeting organizers.

SAN DIEGO — Using intravesical anesthetic treatment and pentosan polysulfate to treat chronic pelvic pain was linked to a significant improvement in symptoms 9 weeks after bladder rescue therapy, a study of 47 women has shown.

The finding “clearly demonstrates that treating the bladder component of pelvic pain can result in significant improvement of symptoms,” Jackie Shriver, a certified registered nurse practitioner with the Lima, Ohio-based Midwest Center for Chronic Pelvic Pain and Bladder Control reported at an international congress of the Society of Laparoendoscopic Surgeons.

In a study led by the center's director, Maurice K. Chung, M.D., investigators conducted a prospective analysis of 47 women aged 21–74 who had a diagnosis of chronic pelvic pain and gynecologic-related symptoms for 6 months. At the initial visit, the women filled out questionnaires that included the Pelvic Pain and Urgency/Frequency (PUF) scale, the American Urological Association (AUA) score, and the Interstitial Cystitis Symptomatology Index (ICSI) score.

Six weeks later, all women underwent potassium sensitivity testing (PST) in the office and filled out the same questionnaires. Of the 47 women, 41 (87%) tested positive on the PST.

The women then underwent intravesical anesthetic treatment and pentosan polysulfate therapy for 9 weeks and filled out the same three questionnaires at the end of treatment.

Intravesical therapy was a solution of 10-cc lidocaine 1%, 10-cc bupivacaine 0.5%, 5-cc sodium bicarbonate, and 40,000-U/4-cc heparin, given biweekly for 3 weeks and then weekly for 6 weeks.

The dosage of pentosan polysulfate therapy was 200 mg b.i.d.

The average baseline scores were 14.8 for the PUF, 13.1 for the AUA, and 8.4 for the ICSI. The 6-week rescreening scores were similar: 15.2 for the PUF, 13 for the AUA, and 8.5 for the ICSI.

However, 9 weeks after bladder rescue therapy, the average scores were 11.1 for the PUF, 9.4 for the AUA, and 5.8 for the ICSI. This demonstrated “significant improvement in symptoms,” Ms. Shriver said.

In an interview, Dr. Chung said wide adoption of this approach could reduce the number of hysterectomies performed in the United States each year. He estimated that 10%–20% of hysterectomies result from a diagnosis of chronic pelvic pain.

The study received an honorable mention by the meeting organizers.

SAN DIEGO — Laparoscopic ligation of broad ligament varicosities in the management of chronic gynecologic pelvic pain is a “safe and relatively simple” procedure, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

“Unlike laparoscopic ligation of ovarian varicosities, laparoscopic ligation of broad ligament varicosities is uncommonly reported in the medical literature,” said Dr. Erian, an ob.gyn. based in Brisbane, Australia.

From March 2000 to November 2004, 15 women with a mean age of 27 and a mean parity of two underwent video laparoscopy at the Royal Brisbane and Women's Hospital to treat unilateral or bilateral broad ligament varicosities. Dr. Erian and his associate, Glenda McLaren, M.D., employed a four-portal entry technique to allow for maximal access and maneuverability of instruments.

The women also underwent diagnostic hysterectomy and endometrial sampling to exclude unsuspected endometrial pathology.

Follow-up was conducted at 1 week, 6 weeks, 3 months, 6 months, and then at yearly intervals. “Adequate communication channels between the family physician and the gynecologic surgeon were maintained at all times,” Dr. Erian said.

At baseline, all study participants reported symptoms of pelvic pain, which they described as heaviness that is present most of the time. The mean operative time was 19 minutes, and the mean estimated blood loss was 10 mL per patient.

Follow-up at 6 weeks and 4 years showed complete or partial resolution of pain to what Dr. Erian described as “a mild and well-tolerated level” in 13 of the 15 women. “In one case, the patient reported considerable midcycle ovulation pain that completely resolved by suppression of ovulation with combined oral contraceptive pills,” he said. “In the last patient in this series, the pain was reported to have not changed. She was referred to a gastroenterologist and was diagnosed with irritable bowel syndrome, and the case was treated accordingly.”

SAN DIEGO — Laparoscopic ligation of broad ligament varicosities in the management of chronic gynecologic pelvic pain is a “safe and relatively simple” procedure, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

“Unlike laparoscopic ligation of ovarian varicosities, laparoscopic ligation of broad ligament varicosities is uncommonly reported in the medical literature,” said Dr. Erian, an ob.gyn. based in Brisbane, Australia.

From March 2000 to November 2004, 15 women with a mean age of 27 and a mean parity of two underwent video laparoscopy at the Royal Brisbane and Women's Hospital to treat unilateral or bilateral broad ligament varicosities. Dr. Erian and his associate, Glenda McLaren, M.D., employed a four-portal entry technique to allow for maximal access and maneuverability of instruments.

The women also underwent diagnostic hysterectomy and endometrial sampling to exclude unsuspected endometrial pathology.

Follow-up was conducted at 1 week, 6 weeks, 3 months, 6 months, and then at yearly intervals. “Adequate communication channels between the family physician and the gynecologic surgeon were maintained at all times,” Dr. Erian said.

At baseline, all study participants reported symptoms of pelvic pain, which they described as heaviness that is present most of the time. The mean operative time was 19 minutes, and the mean estimated blood loss was 10 mL per patient.

Follow-up at 6 weeks and 4 years showed complete or partial resolution of pain to what Dr. Erian described as “a mild and well-tolerated level” in 13 of the 15 women. “In one case, the patient reported considerable midcycle ovulation pain that completely resolved by suppression of ovulation with combined oral contraceptive pills,” he said. “In the last patient in this series, the pain was reported to have not changed. She was referred to a gastroenterologist and was diagnosed with irritable bowel syndrome, and the case was treated accordingly.”

SAN DIEGO — Laparoscopic ligation of broad ligament varicosities in the management of chronic gynecologic pelvic pain is a “safe and relatively simple” procedure, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

“Unlike laparoscopic ligation of ovarian varicosities, laparoscopic ligation of broad ligament varicosities is uncommonly reported in the medical literature,” said Dr. Erian, an ob.gyn. based in Brisbane, Australia.

From March 2000 to November 2004, 15 women with a mean age of 27 and a mean parity of two underwent video laparoscopy at the Royal Brisbane and Women's Hospital to treat unilateral or bilateral broad ligament varicosities. Dr. Erian and his associate, Glenda McLaren, M.D., employed a four-portal entry technique to allow for maximal access and maneuverability of instruments.

The women also underwent diagnostic hysterectomy and endometrial sampling to exclude unsuspected endometrial pathology.

Follow-up was conducted at 1 week, 6 weeks, 3 months, 6 months, and then at yearly intervals. “Adequate communication channels between the family physician and the gynecologic surgeon were maintained at all times,” Dr. Erian said.

At baseline, all study participants reported symptoms of pelvic pain, which they described as heaviness that is present most of the time. The mean operative time was 19 minutes, and the mean estimated blood loss was 10 mL per patient.

Follow-up at 6 weeks and 4 years showed complete or partial resolution of pain to what Dr. Erian described as “a mild and well-tolerated level” in 13 of the 15 women. “In one case, the patient reported considerable midcycle ovulation pain that completely resolved by suppression of ovulation with combined oral contraceptive pills,” he said. “In the last patient in this series, the pain was reported to have not changed. She was referred to a gastroenterologist and was diagnosed with irritable bowel syndrome, and the case was treated accordingly.”

SAN DIEGO — The rising incidence of severe sepsis in the past 2 decades has been accompanied by a decline in the case fatality rate, Charmaine Lewis, M.D., reported in a poster session at the 100th International Conference of the American Thoracic Society.

The incidence of severe sepsis in the United States rose from about 10 cases per 100,000 people in 1979 to 106 cases per 100,000 people in 2002.

“Severe sepsis is a common diagnosis for ICU admission—it's the 10th most common cause of death in the United States, and it's increasing in incidence,” Dr. Lewis told FAMILY PRACTICE NEWS.

Key reasons for the increase since 1979, she said, include the emergence of HIV and the aging population. In addition, “we use a lot more immunosuppressive agents to treat what we used to consider mundane problems, such as rheumatoid arthritis,” said Dr. Lewis, of the division of pulmonary, allergy, and critical care at Emory University, Atlanta.

Meanwhile, the case fatality rate among patients with severe sepsis dropped from 56% in 1979 to 36% in 2002. Fatality rates were highest among patients with respiratory, metabolic, or cardiovascular organ failure, Dr. Lewis said.

Reasons for the decline in deaths remain unclear, she said, but may have to do with improved recognition and treatment of sepsis in acute care settings.

Dr. Lewis and her associates identified patients with severe sepsis by ICD-9 codes for sepsis and acute organ dysfunction contained in National Hospital Discharge Surveys between 1979 and 2002. They normalized incidence rates to the 2002 Census.

From 1979 to 2002 there were 3,302,635 cases of severe sepsis in the United States. Over that period the incidence increased from about 10 cases per 100,000 people in 1979 to a peak of 106 cases per 100,000 people in 2002. The incidence increased about 8.1% per year between 1982 and 2002.

The average age for all patients (65 years) did not change during the study period, but it was slightly lower for men than for women (63 vs. 67 years) and was lowest for African American males (56 years).

Each year about $17 billion is spent on the care of patients with sepsis.

The National Institutes of Health funded the study.

SAN DIEGO — The rising incidence of severe sepsis in the past 2 decades has been accompanied by a decline in the case fatality rate, Charmaine Lewis, M.D., reported in a poster session at the 100th International Conference of the American Thoracic Society.

The incidence of severe sepsis in the United States rose from about 10 cases per 100,000 people in 1979 to 106 cases per 100,000 people in 2002.

“Severe sepsis is a common diagnosis for ICU admission—it's the 10th most common cause of death in the United States, and it's increasing in incidence,” Dr. Lewis told FAMILY PRACTICE NEWS.

Key reasons for the increase since 1979, she said, include the emergence of HIV and the aging population. In addition, “we use a lot more immunosuppressive agents to treat what we used to consider mundane problems, such as rheumatoid arthritis,” said Dr. Lewis, of the division of pulmonary, allergy, and critical care at Emory University, Atlanta.

Meanwhile, the case fatality rate among patients with severe sepsis dropped from 56% in 1979 to 36% in 2002. Fatality rates were highest among patients with respiratory, metabolic, or cardiovascular organ failure, Dr. Lewis said.

Reasons for the decline in deaths remain unclear, she said, but may have to do with improved recognition and treatment of sepsis in acute care settings.

Dr. Lewis and her associates identified patients with severe sepsis by ICD-9 codes for sepsis and acute organ dysfunction contained in National Hospital Discharge Surveys between 1979 and 2002. They normalized incidence rates to the 2002 Census.

From 1979 to 2002 there were 3,302,635 cases of severe sepsis in the United States. Over that period the incidence increased from about 10 cases per 100,000 people in 1979 to a peak of 106 cases per 100,000 people in 2002. The incidence increased about 8.1% per year between 1982 and 2002.

The average age for all patients (65 years) did not change during the study period, but it was slightly lower for men than for women (63 vs. 67 years) and was lowest for African American males (56 years).

Each year about $17 billion is spent on the care of patients with sepsis.

The National Institutes of Health funded the study.

SAN DIEGO — The rising incidence of severe sepsis in the past 2 decades has been accompanied by a decline in the case fatality rate, Charmaine Lewis, M.D., reported in a poster session at the 100th International Conference of the American Thoracic Society.

The incidence of severe sepsis in the United States rose from about 10 cases per 100,000 people in 1979 to 106 cases per 100,000 people in 2002.

“Severe sepsis is a common diagnosis for ICU admission—it's the 10th most common cause of death in the United States, and it's increasing in incidence,” Dr. Lewis told FAMILY PRACTICE NEWS.

Key reasons for the increase since 1979, she said, include the emergence of HIV and the aging population. In addition, “we use a lot more immunosuppressive agents to treat what we used to consider mundane problems, such as rheumatoid arthritis,” said Dr. Lewis, of the division of pulmonary, allergy, and critical care at Emory University, Atlanta.

Meanwhile, the case fatality rate among patients with severe sepsis dropped from 56% in 1979 to 36% in 2002. Fatality rates were highest among patients with respiratory, metabolic, or cardiovascular organ failure, Dr. Lewis said.

Reasons for the decline in deaths remain unclear, she said, but may have to do with improved recognition and treatment of sepsis in acute care settings.

Dr. Lewis and her associates identified patients with severe sepsis by ICD-9 codes for sepsis and acute organ dysfunction contained in National Hospital Discharge Surveys between 1979 and 2002. They normalized incidence rates to the 2002 Census.

From 1979 to 2002 there were 3,302,635 cases of severe sepsis in the United States. Over that period the incidence increased from about 10 cases per 100,000 people in 1979 to a peak of 106 cases per 100,000 people in 2002. The incidence increased about 8.1% per year between 1982 and 2002.

The average age for all patients (65 years) did not change during the study period, but it was slightly lower for men than for women (63 vs. 67 years) and was lowest for African American males (56 years).

Each year about $17 billion is spent on the care of patients with sepsis.

The National Institutes of Health funded the study.

A new statement from the American College of Surgeons endorses the universal adoption of blunt suture needles for all potential applications in the operating room.

“There are surgeons who don't even know that blunt sutures exist for fascial and muscle closure,” said Lena M. Napolitano, M.D., a surgeon who chairs the ACS Committee on Perioperative Care, which assembled the statement. “What we are proposing is that this should become the standard. Rather than using sharp needles to close the fascia and muscle, we should convert to using blunt suture needles because that's the safest for our health care workers in the OR.”

Released in August, the statement (see www.facs.org

The study, conducted by the International Healthcare Worker Safety Center at the University of Virginia Health System, Charlottesville, also found that while injury rates from hollow-bore needles declined by 32.8% between 1993 and 2002, injury rates from suture needles increased by 26.8% over that same period.

“There has been a sea change of progress in [needlestick safety], but most of it has been focused on hollow-bore needles such as syringes, blood-drawing devices, and IV equipment,” said Janine C. Jagger, Ph.D., professor of research and internal medicine at the University of Virginia, Charlottesville, and director of the International Healthcare Worker Safety Center. “The Needlestick Safety and Prevention Act of 2000 requires employers to purchase devices with needlestick prevention features on them. But it seems as though the operating room is the last frontier.”

Dr. Jagger called the new ACS statement on blunt suture needles “an extremely important step” in improving safety for surgeons, health care workers, and patients. “What we do in America has a huge impact elsewhere in the world,” she said, noting that sharp suture needles are the No. 2 cause of needlestick injuries in the hospital setting, right behind syringes. “There are countries that use American standards to set their own standards. Surgical societies around the world will be influenced by this.”

Blunt suture needles have been on the market for more than 10 years. They can be used for suturing most internal tissues, such as muscle, fascia, and fat, but not to suture vascular tissue or skin.

In 2004 they accounted for only about 3% of the suture needle market for general closure. Ethicon Inc. and U.S. Surgical market the needles, which currently cost about 10% more than sharp suture needles.

“When these needles were first developed, there was not much uptake by surgeons,” said Dr. Napolitano, who is also professor of surgery and associate chair for critical care at the University of Michigan, Ann Arbor. “We are a little bit behind [in using them]. I don't think it's a matter of surgeons not embracing [these needles]. I just don't think people know about them.”

She added that switching from sharp suture needles to blunt suture needles requires little change in technique. “Until you use them a couple of times, you do feel a little more resistance to tissue penetration, as you would expect. But you get used to that very quickly,” she said.

Blunt suture needles may not yet be widely accepted in the United States, but they are in Japan, thanks largely to Dr. Jagger, who over the past few years helped that country's surgeons establish a national surveillance program for needlestick injuries and promoted the use of blunt suture needles in the process.

“It was a very simple thing for the Japanese to undergo this transition,” she said, adding that the surgeons there presumed blunt suture needles were part of routine clinical practice in the United States until she informed them otherwise. “There was no resistance. They only found further advantages when they started using them. I've never seen a device transition go so quickly and so smoothly.”

Dr. Jagger said she finds it ironic that surgeons in the United States have not widely adopted them, “especially since they're the simplest and cheapest of all the safety devices. When surgeons start using them, they don't have any objections. The hard part is just to get them to try.”

Dr. Napolitano called the adoption of blunt suture needles in the OR a matter of safety for everyone. “If you've ever seen any health care worker acquire hepatitis or HIV, these are chronic, lifelong diseases, so any prevention we can do is well worth it,” she said.

A new statement from the American College of Surgeons endorses the universal adoption of blunt suture needles for all potential applications in the operating room.

“There are surgeons who don't even know that blunt sutures exist for fascial and muscle closure,” said Lena M. Napolitano, M.D., a surgeon who chairs the ACS Committee on Perioperative Care, which assembled the statement. “What we are proposing is that this should become the standard. Rather than using sharp needles to close the fascia and muscle, we should convert to using blunt suture needles because that's the safest for our health care workers in the OR.”

Released in August, the statement (see www.facs.org

The study, conducted by the International Healthcare Worker Safety Center at the University of Virginia Health System, Charlottesville, also found that while injury rates from hollow-bore needles declined by 32.8% between 1993 and 2002, injury rates from suture needles increased by 26.8% over that same period.

“There has been a sea change of progress in [needlestick safety], but most of it has been focused on hollow-bore needles such as syringes, blood-drawing devices, and IV equipment,” said Janine C. Jagger, Ph.D., professor of research and internal medicine at the University of Virginia, Charlottesville, and director of the International Healthcare Worker Safety Center. “The Needlestick Safety and Prevention Act of 2000 requires employers to purchase devices with needlestick prevention features on them. But it seems as though the operating room is the last frontier.”

Dr. Jagger called the new ACS statement on blunt suture needles “an extremely important step” in improving safety for surgeons, health care workers, and patients. “What we do in America has a huge impact elsewhere in the world,” she said, noting that sharp suture needles are the No. 2 cause of needlestick injuries in the hospital setting, right behind syringes. “There are countries that use American standards to set their own standards. Surgical societies around the world will be influenced by this.”

Blunt suture needles have been on the market for more than 10 years. They can be used for suturing most internal tissues, such as muscle, fascia, and fat, but not to suture vascular tissue or skin.

In 2004 they accounted for only about 3% of the suture needle market for general closure. Ethicon Inc. and U.S. Surgical market the needles, which currently cost about 10% more than sharp suture needles.

“When these needles were first developed, there was not much uptake by surgeons,” said Dr. Napolitano, who is also professor of surgery and associate chair for critical care at the University of Michigan, Ann Arbor. “We are a little bit behind [in using them]. I don't think it's a matter of surgeons not embracing [these needles]. I just don't think people know about them.”

She added that switching from sharp suture needles to blunt suture needles requires little change in technique. “Until you use them a couple of times, you do feel a little more resistance to tissue penetration, as you would expect. But you get used to that very quickly,” she said.

Blunt suture needles may not yet be widely accepted in the United States, but they are in Japan, thanks largely to Dr. Jagger, who over the past few years helped that country's surgeons establish a national surveillance program for needlestick injuries and promoted the use of blunt suture needles in the process.

“It was a very simple thing for the Japanese to undergo this transition,” she said, adding that the surgeons there presumed blunt suture needles were part of routine clinical practice in the United States until she informed them otherwise. “There was no resistance. They only found further advantages when they started using them. I've never seen a device transition go so quickly and so smoothly.”

Dr. Jagger said she finds it ironic that surgeons in the United States have not widely adopted them, “especially since they're the simplest and cheapest of all the safety devices. When surgeons start using them, they don't have any objections. The hard part is just to get them to try.”

Dr. Napolitano called the adoption of blunt suture needles in the OR a matter of safety for everyone. “If you've ever seen any health care worker acquire hepatitis or HIV, these are chronic, lifelong diseases, so any prevention we can do is well worth it,” she said.

A new statement from the American College of Surgeons endorses the universal adoption of blunt suture needles for all potential applications in the operating room.

“There are surgeons who don't even know that blunt sutures exist for fascial and muscle closure,” said Lena M. Napolitano, M.D., a surgeon who chairs the ACS Committee on Perioperative Care, which assembled the statement. “What we are proposing is that this should become the standard. Rather than using sharp needles to close the fascia and muscle, we should convert to using blunt suture needles because that's the safest for our health care workers in the OR.”

Released in August, the statement (see www.facs.org

The study, conducted by the International Healthcare Worker Safety Center at the University of Virginia Health System, Charlottesville, also found that while injury rates from hollow-bore needles declined by 32.8% between 1993 and 2002, injury rates from suture needles increased by 26.8% over that same period.

“There has been a sea change of progress in [needlestick safety], but most of it has been focused on hollow-bore needles such as syringes, blood-drawing devices, and IV equipment,” said Janine C. Jagger, Ph.D., professor of research and internal medicine at the University of Virginia, Charlottesville, and director of the International Healthcare Worker Safety Center. “The Needlestick Safety and Prevention Act of 2000 requires employers to purchase devices with needlestick prevention features on them. But it seems as though the operating room is the last frontier.”

Dr. Jagger called the new ACS statement on blunt suture needles “an extremely important step” in improving safety for surgeons, health care workers, and patients. “What we do in America has a huge impact elsewhere in the world,” she said, noting that sharp suture needles are the No. 2 cause of needlestick injuries in the hospital setting, right behind syringes. “There are countries that use American standards to set their own standards. Surgical societies around the world will be influenced by this.”

Blunt suture needles have been on the market for more than 10 years. They can be used for suturing most internal tissues, such as muscle, fascia, and fat, but not to suture vascular tissue or skin.

In 2004 they accounted for only about 3% of the suture needle market for general closure. Ethicon Inc. and U.S. Surgical market the needles, which currently cost about 10% more than sharp suture needles.

“When these needles were first developed, there was not much uptake by surgeons,” said Dr. Napolitano, who is also professor of surgery and associate chair for critical care at the University of Michigan, Ann Arbor. “We are a little bit behind [in using them]. I don't think it's a matter of surgeons not embracing [these needles]. I just don't think people know about them.”

She added that switching from sharp suture needles to blunt suture needles requires little change in technique. “Until you use them a couple of times, you do feel a little more resistance to tissue penetration, as you would expect. But you get used to that very quickly,” she said.

Blunt suture needles may not yet be widely accepted in the United States, but they are in Japan, thanks largely to Dr. Jagger, who over the past few years helped that country's surgeons establish a national surveillance program for needlestick injuries and promoted the use of blunt suture needles in the process.

“It was a very simple thing for the Japanese to undergo this transition,” she said, adding that the surgeons there presumed blunt suture needles were part of routine clinical practice in the United States until she informed them otherwise. “There was no resistance. They only found further advantages when they started using them. I've never seen a device transition go so quickly and so smoothly.”

Dr. Jagger said she finds it ironic that surgeons in the United States have not widely adopted them, “especially since they're the simplest and cheapest of all the safety devices. When surgeons start using them, they don't have any objections. The hard part is just to get them to try.”

Dr. Napolitano called the adoption of blunt suture needles in the OR a matter of safety for everyone. “If you've ever seen any health care worker acquire hepatitis or HIV, these are chronic, lifelong diseases, so any prevention we can do is well worth it,” she said.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

SAN DIEGO — Some of the telltale signs of dermatomyositis appear on the skin, so it's important to become familiar with them, Ilona S. Szer, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

A malar rash that travels down the nasolabial folds is one common clinical manifestation. A heliotrope rash is another. “Some patients have only swelling without erythema while others have a violaceous hue without much edema,” said Dr. Szer, director of pediatric rheumatology at Children's Hospital San Diego.

Nearly all children with dermatomyositis (DMS) have Gottron's papules that are painless and characterized by red, scaly, palpable erythema. In darker-skinned children, these heal with hypopigmentation or hyperpigmentation.

Cuticle hyperemia is another hallmark of DMS. “These children are not picking on their cuticles,” she said. “They actually have vasculopathy.”

Yet another characteristic sign is a rash over the extensor surface of the elbow. Pediatricians often mistake this for eczema. “Children with DMS who aren't profoundly weak often go on for months with a diagnosis of eczema,” she remarked.

Dr. Szer listed the following “danger signs of DMS” and recommended immediate referral to the hospital if children present with them:

▸ Choking and coughing up food and liquids.

▸ Rapid onset of weakness. “This is unusual, but it happens,” she said. “These children die if we don't take care of them.”

▸ Cutaneous ulcerations. If these are present “you have to worry about GI ulcerations,” she said. “Some children have died because of GI bleeding and perforation of secondary ulcerations. So if you see them, think of internal organs.”

▸ Weight loss.

▸ Fever and pain.

▸ Refusing to sit on the floor, climb stairs, or pick up objects from the floor. “Parents describe this classically but unfortunately it's somehow misinterpreted,” Dr. Szer said. “Most children with DMS don't have acute disease. They have quiet disease that goes undiagnosed for months. The children are described as lazy and weak. The metabolic panel shows AST and ALT elevation. The pediatrician interprets that as hepatitis. That with being lazy and tired becomes mononucleosis; so again, you have a delay in diagnosis.”

The hallmark of a work-up for suspected DMS is a strength exam. “Look for central weakness,” she advised. “Patients with DMS can't lift their heads. Ask them to lift their heads against gravity, ask them to do an unassisted sit-up, and ask them to stand up from [a sitting position on] the floor.”

Lab tests for AST, ALT, lactic dehydrogenase, creatine phosphokinase, and aldolase will be abnormal in DMS, but labs for complete blood count, erythrocyte sedimentation rate, and C-reactive protein are usually normal.

If you're not sure about the presence of myopathy, Dr. Szer recommends an MRI of the truncal muscles. “The T2 image will light up like a lightbulb if there is a myopathy,” she said.

Consider a skin biopsy only if myopathy is absent, she advises, and do a muscle biopsy if no rash is present.

“These children should be followed very carefully for signs of myopathy,” Dr. Szer said. “If that doesn't occur, perhaps Plaquenil [hydroxychloroquine] is the drug of choice.”

The course of DMS is threefold. Children with the monophasic course have the illness once. These children tend to be young (aged 2–3 years) and their prognosis is usually excellent.

Children with the polyphasic course of DMS are usually aged 5 and older. “The first time around, they look monophasic, but as we begin to wean away the medication or after we've weaned them completely, they flare up,” she said. “It may happen once, twice, three times, or 10 times. We don't know who is going to [be polyphasic].”

The third course of the disease, chronic continuous, affects mostly teens. “We have a very hard time treating these patients,” Dr. Szer said. “These are children who are at very high risk for calcinosis. They require prolonged immune suppression.”

Current treatment for severe DMS involves intravenous pulse methylprednisolone with oral steroids and methotrexate. More aggressive treatment options include monthly intravenous IgG, azathioprine, cyclophosphamide, and mycophenolate mofetil.

“As soon as they're feeling better, we work on strength and conditioning and endurance,” she said. “We also encourage and advocate normal function and school attendance.”

DMS isn't the only rheumatic disease that can stump clinicians. Systemic lupus erythematosus is another. Suspect SLE in a young woman with constitutional symptoms and multiorgan manifestations. “I am forever seeing 4-year-old boys with positive ANAs [antinuclear antibody tests] referred to me who are suspected of having lupus,” she said, noting that 90% of cases occur in women (particularly young women).

“I would like everyone to think three times before ordering an ANA because up to 20% of healthy children have positive ANAs,” said Dr. Szer, also a professor of pediatrics at the University of California, San Diego. “That's practically everybody.”

A common cutaneous sign of SLE is a malar rash that spares the nasolabial folds. Other cutaneous signs include discoid rash, photosensitive rash, and recurrent mouth sores.

“Lupus in children is usually insidious,” she added. “It may be acute, but it is always organ- or life-threatening. Delay in diagnosis clearly leads to lupus crisis. There is a point of no return with these patients. There's irreversible renal damage and death.”

Erythrocyte sedimentation rate tends to be very high. Corrected sedimentation rate tends to be normal unless your patient has an infection, and renal disease is found in 90% of children. “The disease is very aggressive in children, especially during the first 2 years,” she said. “We think of this as cancer medicine. We induce things into remission and then we maintain that remission.”

This rash over the extensor surface of the elbow is characteristic of DMS. Courtesy Dr. Ilona S. Szer

SAN DIEGO — Some of the telltale signs of dermatomyositis appear on the skin, so it's important to become familiar with them, Ilona S. Szer, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

A malar rash that travels down the nasolabial folds is one common clinical manifestation. A heliotrope rash is another. “Some patients have only swelling without erythema while others have a violaceous hue without much edema,” said Dr. Szer, director of pediatric rheumatology at Children's Hospital San Diego.

Nearly all children with dermatomyositis (DMS) have Gottron's papules that are painless and characterized by red, scaly, palpable erythema. In darker-skinned children, these heal with hypopigmentation or hyperpigmentation.

Cuticle hyperemia is another hallmark of DMS. “These children are not picking on their cuticles,” she said. “They actually have vasculopathy.”

Yet another characteristic sign is a rash over the extensor surface of the elbow. Pediatricians often mistake this for eczema. “Children with DMS who aren't profoundly weak often go on for months with a diagnosis of eczema,” she remarked.

Dr. Szer listed the following “danger signs of DMS” and recommended immediate referral to the hospital if children present with them:

▸ Choking and coughing up food and liquids.

▸ Rapid onset of weakness. “This is unusual, but it happens,” she said. “These children die if we don't take care of them.”

▸ Cutaneous ulcerations. If these are present “you have to worry about GI ulcerations,” she said. “Some children have died because of GI bleeding and perforation of secondary ulcerations. So if you see them, think of internal organs.”

▸ Weight loss.

▸ Fever and pain.

▸ Refusing to sit on the floor, climb stairs, or pick up objects from the floor. “Parents describe this classically but unfortunately it's somehow misinterpreted,” Dr. Szer said. “Most children with DMS don't have acute disease. They have quiet disease that goes undiagnosed for months. The children are described as lazy and weak. The metabolic panel shows AST and ALT elevation. The pediatrician interprets that as hepatitis. That with being lazy and tired becomes mononucleosis; so again, you have a delay in diagnosis.”

The hallmark of a work-up for suspected DMS is a strength exam. “Look for central weakness,” she advised. “Patients with DMS can't lift their heads. Ask them to lift their heads against gravity, ask them to do an unassisted sit-up, and ask them to stand up from [a sitting position on] the floor.”

Lab tests for AST, ALT, lactic dehydrogenase, creatine phosphokinase, and aldolase will be abnormal in DMS, but labs for complete blood count, erythrocyte sedimentation rate, and C-reactive protein are usually normal.

If you're not sure about the presence of myopathy, Dr. Szer recommends an MRI of the truncal muscles. “The T2 image will light up like a lightbulb if there is a myopathy,” she said.

Consider a skin biopsy only if myopathy is absent, she advises, and do a muscle biopsy if no rash is present.

“These children should be followed very carefully for signs of myopathy,” Dr. Szer said. “If that doesn't occur, perhaps Plaquenil [hydroxychloroquine] is the drug of choice.”

The course of DMS is threefold. Children with the monophasic course have the illness once. These children tend to be young (aged 2–3 years) and their prognosis is usually excellent.

Children with the polyphasic course of DMS are usually aged 5 and older. “The first time around, they look monophasic, but as we begin to wean away the medication or after we've weaned them completely, they flare up,” she said. “It may happen once, twice, three times, or 10 times. We don't know who is going to [be polyphasic].”

The third course of the disease, chronic continuous, affects mostly teens. “We have a very hard time treating these patients,” Dr. Szer said. “These are children who are at very high risk for calcinosis. They require prolonged immune suppression.”

Current treatment for severe DMS involves intravenous pulse methylprednisolone with oral steroids and methotrexate. More aggressive treatment options include monthly intravenous IgG, azathioprine, cyclophosphamide, and mycophenolate mofetil.

“As soon as they're feeling better, we work on strength and conditioning and endurance,” she said. “We also encourage and advocate normal function and school attendance.”

DMS isn't the only rheumatic disease that can stump clinicians. Systemic lupus erythematosus is another. Suspect SLE in a young woman with constitutional symptoms and multiorgan manifestations. “I am forever seeing 4-year-old boys with positive ANAs [antinuclear antibody tests] referred to me who are suspected of having lupus,” she said, noting that 90% of cases occur in women (particularly young women).

“I would like everyone to think three times before ordering an ANA because up to 20% of healthy children have positive ANAs,” said Dr. Szer, also a professor of pediatrics at the University of California, San Diego. “That's practically everybody.”

A common cutaneous sign of SLE is a malar rash that spares the nasolabial folds. Other cutaneous signs include discoid rash, photosensitive rash, and recurrent mouth sores.

“Lupus in children is usually insidious,” she added. “It may be acute, but it is always organ- or life-threatening. Delay in diagnosis clearly leads to lupus crisis. There is a point of no return with these patients. There's irreversible renal damage and death.”

Erythrocyte sedimentation rate tends to be very high. Corrected sedimentation rate tends to be normal unless your patient has an infection, and renal disease is found in 90% of children. “The disease is very aggressive in children, especially during the first 2 years,” she said. “We think of this as cancer medicine. We induce things into remission and then we maintain that remission.”

This rash over the extensor surface of the elbow is characteristic of DMS. Courtesy Dr. Ilona S. Szer

SAN DIEGO — Some of the telltale signs of dermatomyositis appear on the skin, so it's important to become familiar with them, Ilona S. Szer, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

A malar rash that travels down the nasolabial folds is one common clinical manifestation. A heliotrope rash is another. “Some patients have only swelling without erythema while others have a violaceous hue without much edema,” said Dr. Szer, director of pediatric rheumatology at Children's Hospital San Diego.

Nearly all children with dermatomyositis (DMS) have Gottron's papules that are painless and characterized by red, scaly, palpable erythema. In darker-skinned children, these heal with hypopigmentation or hyperpigmentation.

Cuticle hyperemia is another hallmark of DMS. “These children are not picking on their cuticles,” she said. “They actually have vasculopathy.”

Yet another characteristic sign is a rash over the extensor surface of the elbow. Pediatricians often mistake this for eczema. “Children with DMS who aren't profoundly weak often go on for months with a diagnosis of eczema,” she remarked.

Dr. Szer listed the following “danger signs of DMS” and recommended immediate referral to the hospital if children present with them:

▸ Choking and coughing up food and liquids.

▸ Rapid onset of weakness. “This is unusual, but it happens,” she said. “These children die if we don't take care of them.”

▸ Cutaneous ulcerations. If these are present “you have to worry about GI ulcerations,” she said. “Some children have died because of GI bleeding and perforation of secondary ulcerations. So if you see them, think of internal organs.”

▸ Weight loss.

▸ Fever and pain.

▸ Refusing to sit on the floor, climb stairs, or pick up objects from the floor. “Parents describe this classically but unfortunately it's somehow misinterpreted,” Dr. Szer said. “Most children with DMS don't have acute disease. They have quiet disease that goes undiagnosed for months. The children are described as lazy and weak. The metabolic panel shows AST and ALT elevation. The pediatrician interprets that as hepatitis. That with being lazy and tired becomes mononucleosis; so again, you have a delay in diagnosis.”

The hallmark of a work-up for suspected DMS is a strength exam. “Look for central weakness,” she advised. “Patients with DMS can't lift their heads. Ask them to lift their heads against gravity, ask them to do an unassisted sit-up, and ask them to stand up from [a sitting position on] the floor.”

Lab tests for AST, ALT, lactic dehydrogenase, creatine phosphokinase, and aldolase will be abnormal in DMS, but labs for complete blood count, erythrocyte sedimentation rate, and C-reactive protein are usually normal.

If you're not sure about the presence of myopathy, Dr. Szer recommends an MRI of the truncal muscles. “The T2 image will light up like a lightbulb if there is a myopathy,” she said.

Consider a skin biopsy only if myopathy is absent, she advises, and do a muscle biopsy if no rash is present.

“These children should be followed very carefully for signs of myopathy,” Dr. Szer said. “If that doesn't occur, perhaps Plaquenil [hydroxychloroquine] is the drug of choice.”

The course of DMS is threefold. Children with the monophasic course have the illness once. These children tend to be young (aged 2–3 years) and their prognosis is usually excellent.

Children with the polyphasic course of DMS are usually aged 5 and older. “The first time around, they look monophasic, but as we begin to wean away the medication or after we've weaned them completely, they flare up,” she said. “It may happen once, twice, three times, or 10 times. We don't know who is going to [be polyphasic].”

The third course of the disease, chronic continuous, affects mostly teens. “We have a very hard time treating these patients,” Dr. Szer said. “These are children who are at very high risk for calcinosis. They require prolonged immune suppression.”

Current treatment for severe DMS involves intravenous pulse methylprednisolone with oral steroids and methotrexate. More aggressive treatment options include monthly intravenous IgG, azathioprine, cyclophosphamide, and mycophenolate mofetil.

“As soon as they're feeling better, we work on strength and conditioning and endurance,” she said. “We also encourage and advocate normal function and school attendance.”

DMS isn't the only rheumatic disease that can stump clinicians. Systemic lupus erythematosus is another. Suspect SLE in a young woman with constitutional symptoms and multiorgan manifestations. “I am forever seeing 4-year-old boys with positive ANAs [antinuclear antibody tests] referred to me who are suspected of having lupus,” she said, noting that 90% of cases occur in women (particularly young women).

“I would like everyone to think three times before ordering an ANA because up to 20% of healthy children have positive ANAs,” said Dr. Szer, also a professor of pediatrics at the University of California, San Diego. “That's practically everybody.”

A common cutaneous sign of SLE is a malar rash that spares the nasolabial folds. Other cutaneous signs include discoid rash, photosensitive rash, and recurrent mouth sores.

“Lupus in children is usually insidious,” she added. “It may be acute, but it is always organ- or life-threatening. Delay in diagnosis clearly leads to lupus crisis. There is a point of no return with these patients. There's irreversible renal damage and death.”

Erythrocyte sedimentation rate tends to be very high. Corrected sedimentation rate tends to be normal unless your patient has an infection, and renal disease is found in 90% of children. “The disease is very aggressive in children, especially during the first 2 years,” she said. “We think of this as cancer medicine. We induce things into remission and then we maintain that remission.”

This rash over the extensor surface of the elbow is characteristic of DMS. Courtesy Dr. Ilona S. Szer

Postmenopausal women with hormone-sensitive early breast cancer who were switched to anastrozole after 2 years of tamoxifen treatment were 40% less likely to experience disease recurrence, compared with those who remained on tamoxifen, according to a combined analysis of two large European studies.

“There are two possible explanations for this finding: tamoxifen resistance might be overcome by a change in treatment; or aromatase inhibitors might simply be a better treatment option, since they reduce peripheral estrogen concentrations to extremely low levels, whereas tamoxifen is a partial agonist,” wrote the investigators, who were led by Raimund Jakesz, M.D., of Vienna Medical University, Austria.

He and his associates studied the combined results of the Austrian Breast and Colorectal Cancer Study Group trial and the German Adjuvant Breast Cancer Group trial, which were both randomized, prospective, open-label trials with similar inclusion criteria. Eligible patients were postmenopausal women with locally radically treated invasive or minimally invasive breast cancer without previous chemotherapy, hormone therapy, or radiotherapy. The cancers were hormone sensitive (Lancet 2005;366:455–62).

Of the 3,224 women in both trials who had completed at least 2 years of adjuvant oral tamoxifen 20–30 mg daily, 1,618 went on to receive 1 mg of the aromatase inhibitor anastrozole daily while 1,606 continued to receive 20–30 mg of tamoxifen daily for the remainder of their adjuvant therapy. The primary end point was event-free survival, defined as time to relapse at any site or incidence of contralateral breast cancer.

After a median follow-up of 28 months, there were 67 events in women who were switched to anastrozole, compared with 110 in those who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those who were switched to anastrozole, compared with those who remained on tamoxifen. “We noted significantly more fractures and significantly fewer thromboses in patients treated with anastrozole than in those who received only tamoxifen,” Dr. Jakesz and his associates wrote. “However, we also noted a nonsignificant tendency toward fewer emboli and endometrial cancers in women on anastrozole.”

They also pointed out that the results of their investigation “apply only to those women who have successfully completed 2–3 years' adjuvant therapy for early breast cancer. They are not applicable to newly diagnosed patients, and should not be used to support a treatment strategy of starting with tamoxifen with the intention of changing to an aromatase inhibitor after 2 or more years. Overall, however, the results of these studies show the efficacy advantages attached to treatment with an aromatase inhibitor.”

Postmenopausal women with hormone-sensitive early breast cancer who were switched to anastrozole after 2 years of tamoxifen treatment were 40% less likely to experience disease recurrence, compared with those who remained on tamoxifen, according to a combined analysis of two large European studies.

“There are two possible explanations for this finding: tamoxifen resistance might be overcome by a change in treatment; or aromatase inhibitors might simply be a better treatment option, since they reduce peripheral estrogen concentrations to extremely low levels, whereas tamoxifen is a partial agonist,” wrote the investigators, who were led by Raimund Jakesz, M.D., of Vienna Medical University, Austria.

He and his associates studied the combined results of the Austrian Breast and Colorectal Cancer Study Group trial and the German Adjuvant Breast Cancer Group trial, which were both randomized, prospective, open-label trials with similar inclusion criteria. Eligible patients were postmenopausal women with locally radically treated invasive or minimally invasive breast cancer without previous chemotherapy, hormone therapy, or radiotherapy. The cancers were hormone sensitive (Lancet 2005;366:455–62).

Of the 3,224 women in both trials who had completed at least 2 years of adjuvant oral tamoxifen 20–30 mg daily, 1,618 went on to receive 1 mg of the aromatase inhibitor anastrozole daily while 1,606 continued to receive 20–30 mg of tamoxifen daily for the remainder of their adjuvant therapy. The primary end point was event-free survival, defined as time to relapse at any site or incidence of contralateral breast cancer.

After a median follow-up of 28 months, there were 67 events in women who were switched to anastrozole, compared with 110 in those who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those who were switched to anastrozole, compared with those who remained on tamoxifen. “We noted significantly more fractures and significantly fewer thromboses in patients treated with anastrozole than in those who received only tamoxifen,” Dr. Jakesz and his associates wrote. “However, we also noted a nonsignificant tendency toward fewer emboli and endometrial cancers in women on anastrozole.”

They also pointed out that the results of their investigation “apply only to those women who have successfully completed 2–3 years' adjuvant therapy for early breast cancer. They are not applicable to newly diagnosed patients, and should not be used to support a treatment strategy of starting with tamoxifen with the intention of changing to an aromatase inhibitor after 2 or more years. Overall, however, the results of these studies show the efficacy advantages attached to treatment with an aromatase inhibitor.”

Postmenopausal women with hormone-sensitive early breast cancer who were switched to anastrozole after 2 years of tamoxifen treatment were 40% less likely to experience disease recurrence, compared with those who remained on tamoxifen, according to a combined analysis of two large European studies.

“There are two possible explanations for this finding: tamoxifen resistance might be overcome by a change in treatment; or aromatase inhibitors might simply be a better treatment option, since they reduce peripheral estrogen concentrations to extremely low levels, whereas tamoxifen is a partial agonist,” wrote the investigators, who were led by Raimund Jakesz, M.D., of Vienna Medical University, Austria.

He and his associates studied the combined results of the Austrian Breast and Colorectal Cancer Study Group trial and the German Adjuvant Breast Cancer Group trial, which were both randomized, prospective, open-label trials with similar inclusion criteria. Eligible patients were postmenopausal women with locally radically treated invasive or minimally invasive breast cancer without previous chemotherapy, hormone therapy, or radiotherapy. The cancers were hormone sensitive (Lancet 2005;366:455–62).

Of the 3,224 women in both trials who had completed at least 2 years of adjuvant oral tamoxifen 20–30 mg daily, 1,618 went on to receive 1 mg of the aromatase inhibitor anastrozole daily while 1,606 continued to receive 20–30 mg of tamoxifen daily for the remainder of their adjuvant therapy. The primary end point was event-free survival, defined as time to relapse at any site or incidence of contralateral breast cancer.

After a median follow-up of 28 months, there were 67 events in women who were switched to anastrozole, compared with 110 in those who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those who were switched to anastrozole, compared with those who remained on tamoxifen. “We noted significantly more fractures and significantly fewer thromboses in patients treated with anastrozole than in those who received only tamoxifen,” Dr. Jakesz and his associates wrote. “However, we also noted a nonsignificant tendency toward fewer emboli and endometrial cancers in women on anastrozole.”

They also pointed out that the results of their investigation “apply only to those women who have successfully completed 2–3 years' adjuvant therapy for early breast cancer. They are not applicable to newly diagnosed patients, and should not be used to support a treatment strategy of starting with tamoxifen with the intention of changing to an aromatase inhibitor after 2 or more years. Overall, however, the results of these studies show the efficacy advantages attached to treatment with an aromatase inhibitor.”

YOSEMITE, CALIF. — Will my child become a dope fiend?

That's a common question Robert S. McKelvey, M.D., fields from parents of children who are prescribed a class II stimulant for attention-deficit hyperactivity disorder (ADHD).

“The answer is no,” Dr. McKelvey said at a pediatric conference sponsored by Symposia Medicus. “The risk of kids who have properly diagnosed ADHD taking stimulants and becoming dope fiends is no different than [it is for] kids who do not have ADHD. The kids at risk are those who have ADHD” and are not on a prescribed drug treatment. “They have three times the likelihood of developing substance abuse problems,” he said.

Nonstimulant medications are an option for antisocial teens with ADHD, “although, at least in my view, they're not as effective as stimulants,” noted Dr. McKelvey, director of child and adolescent psychiatry at Oregon Health and Science University, Portland. Nonstimulant choices include atomoxetine, bupropion, clonidine, guanfacine, and the tricyclic antidepressants imipramine and nortriptyline.

Another question parents ask is what effect stimulants have on children with a chronic tic disorder such as Tourette's syndrome. “When I was in training, if you had tics, you had a history of tics, or even a family history of tics, we didn't start you on stimulant medication,” he said. “Now there are a couple of studies that show that if you have tics and you take stimulants, it's probably OK as long as the tics don't worsen. Often, the tics seem to [decrease in severity].”

Drugs in the stimulant class are derived from methylphenidate or dextroamphetamine. Methylphenidate is more widely used in the United States, but Dr. McKelvey noted that both agents are equally effective.

“You can't yet predict response, but it's possible that pharmacogenetics studies will give us a hand on that,” he said. “If one of them doesn't work, you try the other.”

A key point to remember about both agents is that they have very short half-lives. Maximal benefit on behavior occurs in 1–2 hours for agents derived from methylphenidate and 3–4 hours for agents derived from dextroamphetamine.

The sustained-release formulations appear to be as effective as the standard short-term formulations. There is some thought that academic performance (such as that associated with inattention) may respond better to a lower dose than do restlessness and impulsivity, he said.

New, long-acting preparations enable once-daily dosing. These include Concerta, Metadate CD, Adderall XR, MethyPatch, and Focalin.

The most common adverse effect of stimulants is decreased appetite, which occurs in 80% of children. “The decreased appetite and weight loss can be stunning in some kids,” he remarked. “I've seen some very skeletal-looking little boys, and it can make you quite nervous.”

Long-term stimulant use may result in about a 1-cm decrease in height per year during the first 3 years of use, “but some of that is caught up,” Dr. McKelvey said. “More recent studies suggest there is perhaps a 1-cm decrease [in height] overall if you take stimulants long term.”

Insomnia is another common side effect, “so you tend to give it earlier in the day. You have to monitor heart and blood pressure. The things you're monitoring are height, weight, and blood pressure. It's pretty straightforward, but yearly, I usually check the white blood cell count,” he said.

He also warned against unproven therapies for ADHD, including megavitamins, biofeedback, sensory integration training, and optometric vision training. “There's a lot of malarkey out there.”

YOSEMITE, CALIF. — Will my child become a dope fiend?

That's a common question Robert S. McKelvey, M.D., fields from parents of children who are prescribed a class II stimulant for attention-deficit hyperactivity disorder (ADHD).

“The answer is no,” Dr. McKelvey said at a pediatric conference sponsored by Symposia Medicus. “The risk of kids who have properly diagnosed ADHD taking stimulants and becoming dope fiends is no different than [it is for] kids who do not have ADHD. The kids at risk are those who have ADHD” and are not on a prescribed drug treatment. “They have three times the likelihood of developing substance abuse problems,” he said.

Nonstimulant medications are an option for antisocial teens with ADHD, “although, at least in my view, they're not as effective as stimulants,” noted Dr. McKelvey, director of child and adolescent psychiatry at Oregon Health and Science University, Portland. Nonstimulant choices include atomoxetine, bupropion, clonidine, guanfacine, and the tricyclic antidepressants imipramine and nortriptyline.

Another question parents ask is what effect stimulants have on children with a chronic tic disorder such as Tourette's syndrome. “When I was in training, if you had tics, you had a history of tics, or even a family history of tics, we didn't start you on stimulant medication,” he said. “Now there are a couple of studies that show that if you have tics and you take stimulants, it's probably OK as long as the tics don't worsen. Often, the tics seem to [decrease in severity].”

Drugs in the stimulant class are derived from methylphenidate or dextroamphetamine. Methylphenidate is more widely used in the United States, but Dr. McKelvey noted that both agents are equally effective.

“You can't yet predict response, but it's possible that pharmacogenetics studies will give us a hand on that,” he said. “If one of them doesn't work, you try the other.”

A key point to remember about both agents is that they have very short half-lives. Maximal benefit on behavior occurs in 1–2 hours for agents derived from methylphenidate and 3–4 hours for agents derived from dextroamphetamine.

The sustained-release formulations appear to be as effective as the standard short-term formulations. There is some thought that academic performance (such as that associated with inattention) may respond better to a lower dose than do restlessness and impulsivity, he said.

New, long-acting preparations enable once-daily dosing. These include Concerta, Metadate CD, Adderall XR, MethyPatch, and Focalin.

The most common adverse effect of stimulants is decreased appetite, which occurs in 80% of children. “The decreased appetite and weight loss can be stunning in some kids,” he remarked. “I've seen some very skeletal-looking little boys, and it can make you quite nervous.”

Long-term stimulant use may result in about a 1-cm decrease in height per year during the first 3 years of use, “but some of that is caught up,” Dr. McKelvey said. “More recent studies suggest there is perhaps a 1-cm decrease [in height] overall if you take stimulants long term.”

Insomnia is another common side effect, “so you tend to give it earlier in the day. You have to monitor heart and blood pressure. The things you're monitoring are height, weight, and blood pressure. It's pretty straightforward, but yearly, I usually check the white blood cell count,” he said.

He also warned against unproven therapies for ADHD, including megavitamins, biofeedback, sensory integration training, and optometric vision training. “There's a lot of malarkey out there.”

YOSEMITE, CALIF. — Will my child become a dope fiend?

That's a common question Robert S. McKelvey, M.D., fields from parents of children who are prescribed a class II stimulant for attention-deficit hyperactivity disorder (ADHD).

“The answer is no,” Dr. McKelvey said at a pediatric conference sponsored by Symposia Medicus. “The risk of kids who have properly diagnosed ADHD taking stimulants and becoming dope fiends is no different than [it is for] kids who do not have ADHD. The kids at risk are those who have ADHD” and are not on a prescribed drug treatment. “They have three times the likelihood of developing substance abuse problems,” he said.

Nonstimulant medications are an option for antisocial teens with ADHD, “although, at least in my view, they're not as effective as stimulants,” noted Dr. McKelvey, director of child and adolescent psychiatry at Oregon Health and Science University, Portland. Nonstimulant choices include atomoxetine, bupropion, clonidine, guanfacine, and the tricyclic antidepressants imipramine and nortriptyline.

Another question parents ask is what effect stimulants have on children with a chronic tic disorder such as Tourette's syndrome. “When I was in training, if you had tics, you had a history of tics, or even a family history of tics, we didn't start you on stimulant medication,” he said. “Now there are a couple of studies that show that if you have tics and you take stimulants, it's probably OK as long as the tics don't worsen. Often, the tics seem to [decrease in severity].”

Drugs in the stimulant class are derived from methylphenidate or dextroamphetamine. Methylphenidate is more widely used in the United States, but Dr. McKelvey noted that both agents are equally effective.

“You can't yet predict response, but it's possible that pharmacogenetics studies will give us a hand on that,” he said. “If one of them doesn't work, you try the other.”

A key point to remember about both agents is that they have very short half-lives. Maximal benefit on behavior occurs in 1–2 hours for agents derived from methylphenidate and 3–4 hours for agents derived from dextroamphetamine.

The sustained-release formulations appear to be as effective as the standard short-term formulations. There is some thought that academic performance (such as that associated with inattention) may respond better to a lower dose than do restlessness and impulsivity, he said.

New, long-acting preparations enable once-daily dosing. These include Concerta, Metadate CD, Adderall XR, MethyPatch, and Focalin.

The most common adverse effect of stimulants is decreased appetite, which occurs in 80% of children. “The decreased appetite and weight loss can be stunning in some kids,” he remarked. “I've seen some very skeletal-looking little boys, and it can make you quite nervous.”

Long-term stimulant use may result in about a 1-cm decrease in height per year during the first 3 years of use, “but some of that is caught up,” Dr. McKelvey said. “More recent studies suggest there is perhaps a 1-cm decrease [in height] overall if you take stimulants long term.”

Insomnia is another common side effect, “so you tend to give it earlier in the day. You have to monitor heart and blood pressure. The things you're monitoring are height, weight, and blood pressure. It's pretty straightforward, but yearly, I usually check the white blood cell count,” he said.

He also warned against unproven therapies for ADHD, including megavitamins, biofeedback, sensory integration training, and optometric vision training. “There's a lot of malarkey out there.”