Doug Brunk

Maternal celiac disease, undiagnosed at the time of delivery, is a risk factor for adverse fetal outcomes, but celiac disease diagnosed before giving birth is not associated with such outcomes, results from a large Swedish population study suggest.

“Our results underline the importance of screening for CD [celiac disease] among women of reproductive age because some 1% of young people may have CD, and treatment seems to reduce dramatically the rate of complications in pregnancy,” reported the investigators, led by Jonas F. Ludvigsson, M.D., of the pediatric department at örebro University Hospital, Sweden.

Celiac disease is a chronic intestinal malabsorption disorder caused by intolerance to gluten. Diagnosis is suspected on the basis of symptoms, enhanced by laboratory and x-ray studies, confirmed by biopsy, and improved by going on a gluten-free diet, which is the only treatment for this disorder.

Using a national medical registry, Ludvigsson and his associates identified 2,078 women aged 15–44 with a diagnosis of CD who delivered singleton live-born infants from 1973 to 2001. A total of 1,149 women were diagnosed with CD before giving birth, and 929 were diagnosed after giving birth (Gastroenterology 2005;129:454–63).

After adjusting for potential confounding factors such as smoking, age, parity, and diabetes mellitus, the subjects diagnosed with CD after the birth of their offspring were associated with an increased risk of intrauterine growth retardation (odds ratio of 1.62), preterm birth (OR 1.71), cesarean section (OR 1.82), low birth weight (OR 2.13), and very low birth weight (OR 2.45). Subjects diagnosed with CD before the birth of their offspring were not significantly associated with an increased risk of these outcomes.

The investigators reported that the risk for nearly all adverse outcomes was highest among women who received a diagnosis of CD during the 5 years after giving birth.

They postulated that insufficient fetal nutrition causes the increased risk of intrauterine growth retardation and low birth weight seen in offspring of women diagnosed after giving birth.

Maternal celiac disease, undiagnosed at the time of delivery, is a risk factor for adverse fetal outcomes, but celiac disease diagnosed before giving birth is not associated with such outcomes, results from a large Swedish population study suggest.

“Our results underline the importance of screening for CD [celiac disease] among women of reproductive age because some 1% of young people may have CD, and treatment seems to reduce dramatically the rate of complications in pregnancy,” reported the investigators, led by Jonas F. Ludvigsson, M.D., of the pediatric department at örebro University Hospital, Sweden.

Celiac disease is a chronic intestinal malabsorption disorder caused by intolerance to gluten. Diagnosis is suspected on the basis of symptoms, enhanced by laboratory and x-ray studies, confirmed by biopsy, and improved by going on a gluten-free diet, which is the only treatment for this disorder.

Using a national medical registry, Ludvigsson and his associates identified 2,078 women aged 15–44 with a diagnosis of CD who delivered singleton live-born infants from 1973 to 2001. A total of 1,149 women were diagnosed with CD before giving birth, and 929 were diagnosed after giving birth (Gastroenterology 2005;129:454–63).

After adjusting for potential confounding factors such as smoking, age, parity, and diabetes mellitus, the subjects diagnosed with CD after the birth of their offspring were associated with an increased risk of intrauterine growth retardation (odds ratio of 1.62), preterm birth (OR 1.71), cesarean section (OR 1.82), low birth weight (OR 2.13), and very low birth weight (OR 2.45). Subjects diagnosed with CD before the birth of their offspring were not significantly associated with an increased risk of these outcomes.

The investigators reported that the risk for nearly all adverse outcomes was highest among women who received a diagnosis of CD during the 5 years after giving birth.

They postulated that insufficient fetal nutrition causes the increased risk of intrauterine growth retardation and low birth weight seen in offspring of women diagnosed after giving birth.

Maternal celiac disease, undiagnosed at the time of delivery, is a risk factor for adverse fetal outcomes, but celiac disease diagnosed before giving birth is not associated with such outcomes, results from a large Swedish population study suggest.

“Our results underline the importance of screening for CD [celiac disease] among women of reproductive age because some 1% of young people may have CD, and treatment seems to reduce dramatically the rate of complications in pregnancy,” reported the investigators, led by Jonas F. Ludvigsson, M.D., of the pediatric department at örebro University Hospital, Sweden.

Celiac disease is a chronic intestinal malabsorption disorder caused by intolerance to gluten. Diagnosis is suspected on the basis of symptoms, enhanced by laboratory and x-ray studies, confirmed by biopsy, and improved by going on a gluten-free diet, which is the only treatment for this disorder.

Using a national medical registry, Ludvigsson and his associates identified 2,078 women aged 15–44 with a diagnosis of CD who delivered singleton live-born infants from 1973 to 2001. A total of 1,149 women were diagnosed with CD before giving birth, and 929 were diagnosed after giving birth (Gastroenterology 2005;129:454–63).

After adjusting for potential confounding factors such as smoking, age, parity, and diabetes mellitus, the subjects diagnosed with CD after the birth of their offspring were associated with an increased risk of intrauterine growth retardation (odds ratio of 1.62), preterm birth (OR 1.71), cesarean section (OR 1.82), low birth weight (OR 2.13), and very low birth weight (OR 2.45). Subjects diagnosed with CD before the birth of their offspring were not significantly associated with an increased risk of these outcomes.

The investigators reported that the risk for nearly all adverse outcomes was highest among women who received a diagnosis of CD during the 5 years after giving birth.

They postulated that insufficient fetal nutrition causes the increased risk of intrauterine growth retardation and low birth weight seen in offspring of women diagnosed after giving birth.

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 who participated in both trials and 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, which was 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 patients who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those women 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.”

The researchers 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 added that the results 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. …”

Dr. Jakesz and his associates concluded that further investigation of aromatase inhibitors is needed in order to more accurately “ascertain the ideal sequence and duration” of therapy.

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 who participated in both trials and 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, which was 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 patients who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those women 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.”

The researchers 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 added that the results 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. …”

Dr. Jakesz and his associates concluded that further investigation of aromatase inhibitors is needed in order to more accurately “ascertain the ideal sequence and duration” of therapy.

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 who participated in both trials and 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, which was 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 patients who remained on tamoxifen. This translates into a 40% decrease in the risk of an event for those women 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.”

The researchers 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 added that the results 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. …”

Dr. Jakesz and his associates concluded that further investigation of aromatase inhibitors is needed in order to more accurately “ascertain the ideal sequence and duration” of therapy.

YOSEMITE, CALIF. — Be ready to provide an opportunity for adolescent patients to ask questions about a sensitive topic like sex, Richard G. MacKenzie, M.D., advised at a pediatric conference sponsored by Symposia Medicus.

“Sometimes kids have questions in areas that they sometimes feel hesitant or embarrassed to ask [you about],” said Dr. MacKenzie, director of the division of adolescent medicine at Children's Hospital Los Angeles. “I'll say, 'If you don't feel comfortable asking me questions as your physician in a confidential way, then I think we need to help find another physician for you because you should be able to ask questions of someone that you trust and who knows of your personal and private life.'”

Building a trusting relationship that allows for confidentiality includes encouraging parents to talk to their kids about sensitive topics, “if for no other reason than to raise these as concerns so their teens can bring questions to you as their advised health care provider,” he said.

Dr. MacKenzie discussed common questions about sex that young women have posed to him over the years:

▸ Do my parents have to know if I go to the doctor for birth control or for a checkup? In most states the answer is no. In California, for example, “a minor may receive birth control without parental consent, and a minor may consent to medical care related to the prevention or treatment of pregnancy, except sterilization,” Dr. MacKenzie said. “The health care provider is not permitted to inform the parent or legal guardian, and the parent or legal guardian is not responsible for the bill that young person generates.”

For a resource, he recommended the “Adolescent Provider Toolkit,” a guide to treating teen parents. It can be found on the Web site of the San Francisco-based Adolescent Health Working Group (http://ahwg.net

▸ Can a girl get pregnant when she is having sex on her period? “For those of us who know the standard knowledge base about menstruation and pregnancy, the simple answer is no, but there are exceptions,” said Dr. MacKenzie, also of the departments of pediatrics and medicine at the University of Southern California, Los Angeles.

The biologic conditions for normal pregnancy are ovulation, a patent fallopian tube, motile healthy sperm, and a receptive endometrium.

However, he noted that about 10%–15% of a teen's menstrual cycles are characterized by midcycle bleeding, “which is ovulatory bleeding and is usually accompanied by a small amount of brownish-colored blood,” he explained. “To the novice, this may look like menstruation,” so the woman may mistakenly presume that she can't get pregnant.

Some investigators hypothesize that sexual arousal may actually stimulate ovulation, thus mimicking an estrus cycle, a phenomenon seen in rabbits.

“Menses is an evolution of the estrus cycle, a reproductive cycle in which ovulation occurs secondary to sexual arousal and stimulation,” Dr. MacKenzie explained. “Anecdotally, women have reported getting pregnant 'against all odds,' having coitus only during their menstrual period. Some clinicians feel that a woman may regress to the estrus cycle with stimulation. She may actually ovulate secondary to sexual stimulation. If the other conditions are right, she may become pregnant.”

▸ Can I get a sexually transmitted disease from oral sex? The answer is, “for sure,” he said. STDs that can be transmitted during oral sex include gonorrhea, herpes simplex virus, chlamydia, human papilloma virus, chancroid, and syphilis.

“The reason this question comes up is that there is this feeling amongst young people that oral sex is not sex at all,” he noted. “It's another way of sexual satisfaction, but it's not considered sex in their minds.”

▸ Can you be pregnant and still have your period? The answer is yes. This can happen during spurious menses, a condition in which pregnant women continue to have abbreviated menses for the first two to three cycles after fertilization. “I've seen a number of young women whom I thought on my history taking and my exam were not pregnant but ended up being pregnant [because of this condition],” Dr. MacKenzie said.

Implantation bleeding is another cause. “This occurs in 25% of females 5–12 days after ovulation, [which is] roughly the time of their menstrual period, so it can be seen as a period,” he said.

Ectopic pregnancy, blighted ovum, and molar pregnancy also may produce vaginal bleeding that is mistaken for menses.

▸ Can a girl get pregnant even though she hasn't had her period yet? This question “probably speaks to 13-year-olds who are talking about having premenarchal sex,” Dr. MacKenzie said. “It's extremely unlikely,” but there are occasional reports.

▸ Why do some women bleed when they have sex? “We're taught in medical school that postcoital bleeding is a bad sign because it's often related to cervical carcinoma, but it may also be related to cervical ectropion, a stage of the developing cervix that exposes the columnar cells of the endocervical canal to the 'trauma' of coitus,” he said.

Other causes of bleeding during sex may include cervical dysplasia, cervicitis, vaginitis, cervical or uterine polyps, and trauma, such as coagulopathy.

▸ What does an abnormal Pap smear mean? The best reply is to tell the young woman that abnormal cells have been identified. The majority of abnormal Pap results (90%–95%) are a consequence of HPV infections “in all ages of the population, not just in adolescents,” Dr. MacKenzie said.

Other contributing factors to an abnormal Pap include cigarette smoking, the early onset of coitus, and having multiple sexual partners.

YOSEMITE, CALIF. — Be ready to provide an opportunity for adolescent patients to ask questions about a sensitive topic like sex, Richard G. MacKenzie, M.D., advised at a pediatric conference sponsored by Symposia Medicus.

“Sometimes kids have questions in areas that they sometimes feel hesitant or embarrassed to ask [you about],” said Dr. MacKenzie, director of the division of adolescent medicine at Children's Hospital Los Angeles. “I'll say, 'If you don't feel comfortable asking me questions as your physician in a confidential way, then I think we need to help find another physician for you because you should be able to ask questions of someone that you trust and who knows of your personal and private life.'”

Building a trusting relationship that allows for confidentiality includes encouraging parents to talk to their kids about sensitive topics, “if for no other reason than to raise these as concerns so their teens can bring questions to you as their advised health care provider,” he said.

Dr. MacKenzie discussed common questions about sex that young women have posed to him over the years:

▸ Do my parents have to know if I go to the doctor for birth control or for a checkup? In most states the answer is no. In California, for example, “a minor may receive birth control without parental consent, and a minor may consent to medical care related to the prevention or treatment of pregnancy, except sterilization,” Dr. MacKenzie said. “The health care provider is not permitted to inform the parent or legal guardian, and the parent or legal guardian is not responsible for the bill that young person generates.”

For a resource, he recommended the “Adolescent Provider Toolkit,” a guide to treating teen parents. It can be found on the Web site of the San Francisco-based Adolescent Health Working Group (http://ahwg.net

▸ Can a girl get pregnant when she is having sex on her period? “For those of us who know the standard knowledge base about menstruation and pregnancy, the simple answer is no, but there are exceptions,” said Dr. MacKenzie, also of the departments of pediatrics and medicine at the University of Southern California, Los Angeles.

The biologic conditions for normal pregnancy are ovulation, a patent fallopian tube, motile healthy sperm, and a receptive endometrium.

However, he noted that about 10%–15% of a teen's menstrual cycles are characterized by midcycle bleeding, “which is ovulatory bleeding and is usually accompanied by a small amount of brownish-colored blood,” he explained. “To the novice, this may look like menstruation,” so the woman may mistakenly presume that she can't get pregnant.

Some investigators hypothesize that sexual arousal may actually stimulate ovulation, thus mimicking an estrus cycle, a phenomenon seen in rabbits.

“Menses is an evolution of the estrus cycle, a reproductive cycle in which ovulation occurs secondary to sexual arousal and stimulation,” Dr. MacKenzie explained. “Anecdotally, women have reported getting pregnant 'against all odds,' having coitus only during their menstrual period. Some clinicians feel that a woman may regress to the estrus cycle with stimulation. She may actually ovulate secondary to sexual stimulation. If the other conditions are right, she may become pregnant.”

▸ Can I get a sexually transmitted disease from oral sex? The answer is, “for sure,” he said. STDs that can be transmitted during oral sex include gonorrhea, herpes simplex virus, chlamydia, human papilloma virus, chancroid, and syphilis.

“The reason this question comes up is that there is this feeling amongst young people that oral sex is not sex at all,” he noted. “It's another way of sexual satisfaction, but it's not considered sex in their minds.”

▸ Can you be pregnant and still have your period? The answer is yes. This can happen during spurious menses, a condition in which pregnant women continue to have abbreviated menses for the first two to three cycles after fertilization. “I've seen a number of young women whom I thought on my history taking and my exam were not pregnant but ended up being pregnant [because of this condition],” Dr. MacKenzie said.

Implantation bleeding is another cause. “This occurs in 25% of females 5–12 days after ovulation, [which is] roughly the time of their menstrual period, so it can be seen as a period,” he said.

Ectopic pregnancy, blighted ovum, and molar pregnancy also may produce vaginal bleeding that is mistaken for menses.

▸ Can a girl get pregnant even though she hasn't had her period yet? This question “probably speaks to 13-year-olds who are talking about having premenarchal sex,” Dr. MacKenzie said. “It's extremely unlikely,” but there are occasional reports.

▸ Why do some women bleed when they have sex? “We're taught in medical school that postcoital bleeding is a bad sign because it's often related to cervical carcinoma, but it may also be related to cervical ectropion, a stage of the developing cervix that exposes the columnar cells of the endocervical canal to the 'trauma' of coitus,” he said.

Other causes of bleeding during sex may include cervical dysplasia, cervicitis, vaginitis, cervical or uterine polyps, and trauma, such as coagulopathy.

▸ What does an abnormal Pap smear mean? The best reply is to tell the young woman that abnormal cells have been identified. The majority of abnormal Pap results (90%–95%) are a consequence of HPV infections “in all ages of the population, not just in adolescents,” Dr. MacKenzie said.

Other contributing factors to an abnormal Pap include cigarette smoking, the early onset of coitus, and having multiple sexual partners.

YOSEMITE, CALIF. — Be ready to provide an opportunity for adolescent patients to ask questions about a sensitive topic like sex, Richard G. MacKenzie, M.D., advised at a pediatric conference sponsored by Symposia Medicus.

“Sometimes kids have questions in areas that they sometimes feel hesitant or embarrassed to ask [you about],” said Dr. MacKenzie, director of the division of adolescent medicine at Children's Hospital Los Angeles. “I'll say, 'If you don't feel comfortable asking me questions as your physician in a confidential way, then I think we need to help find another physician for you because you should be able to ask questions of someone that you trust and who knows of your personal and private life.'”

Building a trusting relationship that allows for confidentiality includes encouraging parents to talk to their kids about sensitive topics, “if for no other reason than to raise these as concerns so their teens can bring questions to you as their advised health care provider,” he said.

Dr. MacKenzie discussed common questions about sex that young women have posed to him over the years:

▸ Do my parents have to know if I go to the doctor for birth control or for a checkup? In most states the answer is no. In California, for example, “a minor may receive birth control without parental consent, and a minor may consent to medical care related to the prevention or treatment of pregnancy, except sterilization,” Dr. MacKenzie said. “The health care provider is not permitted to inform the parent or legal guardian, and the parent or legal guardian is not responsible for the bill that young person generates.”

For a resource, he recommended the “Adolescent Provider Toolkit,” a guide to treating teen parents. It can be found on the Web site of the San Francisco-based Adolescent Health Working Group (http://ahwg.net

▸ Can a girl get pregnant when she is having sex on her period? “For those of us who know the standard knowledge base about menstruation and pregnancy, the simple answer is no, but there are exceptions,” said Dr. MacKenzie, also of the departments of pediatrics and medicine at the University of Southern California, Los Angeles.

The biologic conditions for normal pregnancy are ovulation, a patent fallopian tube, motile healthy sperm, and a receptive endometrium.

However, he noted that about 10%–15% of a teen's menstrual cycles are characterized by midcycle bleeding, “which is ovulatory bleeding and is usually accompanied by a small amount of brownish-colored blood,” he explained. “To the novice, this may look like menstruation,” so the woman may mistakenly presume that she can't get pregnant.

Some investigators hypothesize that sexual arousal may actually stimulate ovulation, thus mimicking an estrus cycle, a phenomenon seen in rabbits.

“Menses is an evolution of the estrus cycle, a reproductive cycle in which ovulation occurs secondary to sexual arousal and stimulation,” Dr. MacKenzie explained. “Anecdotally, women have reported getting pregnant 'against all odds,' having coitus only during their menstrual period. Some clinicians feel that a woman may regress to the estrus cycle with stimulation. She may actually ovulate secondary to sexual stimulation. If the other conditions are right, she may become pregnant.”

▸ Can I get a sexually transmitted disease from oral sex? The answer is, “for sure,” he said. STDs that can be transmitted during oral sex include gonorrhea, herpes simplex virus, chlamydia, human papilloma virus, chancroid, and syphilis.

“The reason this question comes up is that there is this feeling amongst young people that oral sex is not sex at all,” he noted. “It's another way of sexual satisfaction, but it's not considered sex in their minds.”

▸ Can you be pregnant and still have your period? The answer is yes. This can happen during spurious menses, a condition in which pregnant women continue to have abbreviated menses for the first two to three cycles after fertilization. “I've seen a number of young women whom I thought on my history taking and my exam were not pregnant but ended up being pregnant [because of this condition],” Dr. MacKenzie said.

Implantation bleeding is another cause. “This occurs in 25% of females 5–12 days after ovulation, [which is] roughly the time of their menstrual period, so it can be seen as a period,” he said.

Ectopic pregnancy, blighted ovum, and molar pregnancy also may produce vaginal bleeding that is mistaken for menses.

▸ Can a girl get pregnant even though she hasn't had her period yet? This question “probably speaks to 13-year-olds who are talking about having premenarchal sex,” Dr. MacKenzie said. “It's extremely unlikely,” but there are occasional reports.

▸ Why do some women bleed when they have sex? “We're taught in medical school that postcoital bleeding is a bad sign because it's often related to cervical carcinoma, but it may also be related to cervical ectropion, a stage of the developing cervix that exposes the columnar cells of the endocervical canal to the 'trauma' of coitus,” he said.

Other causes of bleeding during sex may include cervical dysplasia, cervicitis, vaginitis, cervical or uterine polyps, and trauma, such as coagulopathy.

▸ What does an abnormal Pap smear mean? The best reply is to tell the young woman that abnormal cells have been identified. The majority of abnormal Pap results (90%–95%) are a consequence of HPV infections “in all ages of the population, not just in adolescents,” Dr. MacKenzie said.

Other contributing factors to an abnormal Pap include cigarette smoking, the early onset of coitus, and having multiple sexual partners.

SAN DIEGO — Although deep fungal infections are rarely seen in North American children, they can present in those who visit or emigrate from tropical or subtropical areas of the world, Hector Caceres-Rios, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Caceres-Rios, professor of dermatology at Cayetano Heredia University, Lima, Peru, discussed several deep fungal infections:

▸ Mycetoma. This infection is seen mostly in Africa, India, Mexico, and Brazil. It typically peaks in the 3rd to 5th decade of life, but in Mexico it has been reported in 35% of citizens aged 16–30 years.

Infection occurs from inoculation with thorns, splinters, and sometimes animal bites, and incubation ranges from weeks to years. The disease course can last from months to decades.

The two main forms are eumycotic mycetoma and actinomycotic mycetoma.

Eumycotic mycetoma is typically restricted to the lower limbs (the foot in 70% of cases).

Causative agents include eumycota, dark grains, and white grains.

Eumycotic mycetoma is characterized by a painless swelling with multiple fistulae that discharge grains.

It may spread to the spinal cord, muscles, bones, and viscera. Treatment includes surgery and long-term use of ketoconazole or itraconazole.

Actinomycotic mycetoma is clinically similar to eumycotic mycetoma but is more painful. Causative agents typically include the Nocardia and Streptomyces species of aerobic bacteria.

Nocardia brasiliensis may cause inflammation at the affected site, while Actinomadura madurae causes the site to take on a “woody consistency,” he said.

Long-term antimicrobial therapy with streptomycin plus sulfamethoxazole and trimethoprim is required for these patients.

▸ Sporotrichosis. This infection is caused by skin injury with contaminated material or inhalation into the lungs. The culprit is Sporothrix schenckii, a dimorphous fungus. The infection primarily affects cutaneous tissue and lymphatic tissue but may also affect bones, joints, and viscera.

Dr. Caceres-Rios said that Mexico, Peru, and Colombia are the major endemic areas. Incubation varies from 1 week to 6 months, and first lesions usually appear on the extremities, followed by regional adenopathy. Treatment involves itraconazole 5 mg/kg per day for 16 weeks.

The infection occurs mainly in adults, but in some endemic areas of Peru, 60% of the cases occur in children under age 15.

▸ Chromoblastomycosis. This infection is caused by pigmented dematiaceous fungi, which generate dark yeasts. The disease is most prevalent in Madagascar, Brazil, and the Caribbean, and it presents in five clinical forms: nodular, tumoral, verrucous, plaquelike, and scar.

The disease typically peaks in the 3rd to 5th decade of life, but infection in children has been reported (Ann. Trop. Paediatr. 1990;10:273–7). Adults commonly present with the verrucous form, whereas children typically have nodular and plaquelike lesions.

This disease “may be extremely indolent, lasting for more than 20 years,” Dr. Caceres-Rios said.

▸ Paracoccidioidomycosis. According to Dr. Caceres-Rios, this is “the most important systemic mycosis in Brazil, Peru, and Mexico.” This infection is caused by Paracoccidioides brasiliensis, a dimorphous fungus. Common signs include warty, ulcerated, crusty lesions on the face and limbs.

The disease peaks in middle age, but in Brazil nearly 6% of affected patients are children. Paracoccidioidomycosis is mainly a pulmonary infection, but it may disseminate to other organs.

The most common form, disseminated paracoccidioidomycosis, is characterized by pulmonary, mucocutaneous, and lymph node involvement. Oral lesions occur in 80% of adults with this form.

Skin lesions are usually painful ulcerative or verrucous plaques. He said he treats severe cases with amphotericin.

Eumycotic mycetoma of the foot is treated with surgery and long-term use of ketoconazole or itraconazole.

Localized sporotrichosis in a child is treated with itraconazole 5 mg/kg per day for 16 weeks. Photos courtesy Dr. Hector Caceres-Rios

SAN DIEGO — Although deep fungal infections are rarely seen in North American children, they can present in those who visit or emigrate from tropical or subtropical areas of the world, Hector Caceres-Rios, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Caceres-Rios, professor of dermatology at Cayetano Heredia University, Lima, Peru, discussed several deep fungal infections:

▸ Mycetoma. This infection is seen mostly in Africa, India, Mexico, and Brazil. It typically peaks in the 3rd to 5th decade of life, but in Mexico it has been reported in 35% of citizens aged 16–30 years.

Infection occurs from inoculation with thorns, splinters, and sometimes animal bites, and incubation ranges from weeks to years. The disease course can last from months to decades.

The two main forms are eumycotic mycetoma and actinomycotic mycetoma.

Eumycotic mycetoma is typically restricted to the lower limbs (the foot in 70% of cases).

Causative agents include eumycota, dark grains, and white grains.

Eumycotic mycetoma is characterized by a painless swelling with multiple fistulae that discharge grains.

It may spread to the spinal cord, muscles, bones, and viscera. Treatment includes surgery and long-term use of ketoconazole or itraconazole.

Actinomycotic mycetoma is clinically similar to eumycotic mycetoma but is more painful. Causative agents typically include the Nocardia and Streptomyces species of aerobic bacteria.

Nocardia brasiliensis may cause inflammation at the affected site, while Actinomadura madurae causes the site to take on a “woody consistency,” he said.

Long-term antimicrobial therapy with streptomycin plus sulfamethoxazole and trimethoprim is required for these patients.

▸ Sporotrichosis. This infection is caused by skin injury with contaminated material or inhalation into the lungs. The culprit is Sporothrix schenckii, a dimorphous fungus. The infection primarily affects cutaneous tissue and lymphatic tissue but may also affect bones, joints, and viscera.

Dr. Caceres-Rios said that Mexico, Peru, and Colombia are the major endemic areas. Incubation varies from 1 week to 6 months, and first lesions usually appear on the extremities, followed by regional adenopathy. Treatment involves itraconazole 5 mg/kg per day for 16 weeks.

The infection occurs mainly in adults, but in some endemic areas of Peru, 60% of the cases occur in children under age 15.

▸ Chromoblastomycosis. This infection is caused by pigmented dematiaceous fungi, which generate dark yeasts. The disease is most prevalent in Madagascar, Brazil, and the Caribbean, and it presents in five clinical forms: nodular, tumoral, verrucous, plaquelike, and scar.

The disease typically peaks in the 3rd to 5th decade of life, but infection in children has been reported (Ann. Trop. Paediatr. 1990;10:273–7). Adults commonly present with the verrucous form, whereas children typically have nodular and plaquelike lesions.

This disease “may be extremely indolent, lasting for more than 20 years,” Dr. Caceres-Rios said.

▸ Paracoccidioidomycosis. According to Dr. Caceres-Rios, this is “the most important systemic mycosis in Brazil, Peru, and Mexico.” This infection is caused by Paracoccidioides brasiliensis, a dimorphous fungus. Common signs include warty, ulcerated, crusty lesions on the face and limbs.

The disease peaks in middle age, but in Brazil nearly 6% of affected patients are children. Paracoccidioidomycosis is mainly a pulmonary infection, but it may disseminate to other organs.

The most common form, disseminated paracoccidioidomycosis, is characterized by pulmonary, mucocutaneous, and lymph node involvement. Oral lesions occur in 80% of adults with this form.

Skin lesions are usually painful ulcerative or verrucous plaques. He said he treats severe cases with amphotericin.

Eumycotic mycetoma of the foot is treated with surgery and long-term use of ketoconazole or itraconazole.

Localized sporotrichosis in a child is treated with itraconazole 5 mg/kg per day for 16 weeks. Photos courtesy Dr. Hector Caceres-Rios

SAN DIEGO — Although deep fungal infections are rarely seen in North American children, they can present in those who visit or emigrate from tropical or subtropical areas of the world, Hector Caceres-Rios, M.D., said at the annual meeting of the Society for Pediatric Dermatology.

Dr. Caceres-Rios, professor of dermatology at Cayetano Heredia University, Lima, Peru, discussed several deep fungal infections:

▸ Mycetoma. This infection is seen mostly in Africa, India, Mexico, and Brazil. It typically peaks in the 3rd to 5th decade of life, but in Mexico it has been reported in 35% of citizens aged 16–30 years.

Infection occurs from inoculation with thorns, splinters, and sometimes animal bites, and incubation ranges from weeks to years. The disease course can last from months to decades.

The two main forms are eumycotic mycetoma and actinomycotic mycetoma.

Eumycotic mycetoma is typically restricted to the lower limbs (the foot in 70% of cases).

Causative agents include eumycota, dark grains, and white grains.

Eumycotic mycetoma is characterized by a painless swelling with multiple fistulae that discharge grains.

It may spread to the spinal cord, muscles, bones, and viscera. Treatment includes surgery and long-term use of ketoconazole or itraconazole.

Actinomycotic mycetoma is clinically similar to eumycotic mycetoma but is more painful. Causative agents typically include the Nocardia and Streptomyces species of aerobic bacteria.

Nocardia brasiliensis may cause inflammation at the affected site, while Actinomadura madurae causes the site to take on a “woody consistency,” he said.

Long-term antimicrobial therapy with streptomycin plus sulfamethoxazole and trimethoprim is required for these patients.

▸ Sporotrichosis. This infection is caused by skin injury with contaminated material or inhalation into the lungs. The culprit is Sporothrix schenckii, a dimorphous fungus. The infection primarily affects cutaneous tissue and lymphatic tissue but may also affect bones, joints, and viscera.

Dr. Caceres-Rios said that Mexico, Peru, and Colombia are the major endemic areas. Incubation varies from 1 week to 6 months, and first lesions usually appear on the extremities, followed by regional adenopathy. Treatment involves itraconazole 5 mg/kg per day for 16 weeks.

The infection occurs mainly in adults, but in some endemic areas of Peru, 60% of the cases occur in children under age 15.

▸ Chromoblastomycosis. This infection is caused by pigmented dematiaceous fungi, which generate dark yeasts. The disease is most prevalent in Madagascar, Brazil, and the Caribbean, and it presents in five clinical forms: nodular, tumoral, verrucous, plaquelike, and scar.

The disease typically peaks in the 3rd to 5th decade of life, but infection in children has been reported (Ann. Trop. Paediatr. 1990;10:273–7). Adults commonly present with the verrucous form, whereas children typically have nodular and plaquelike lesions.

This disease “may be extremely indolent, lasting for more than 20 years,” Dr. Caceres-Rios said.

▸ Paracoccidioidomycosis. According to Dr. Caceres-Rios, this is “the most important systemic mycosis in Brazil, Peru, and Mexico.” This infection is caused by Paracoccidioides brasiliensis, a dimorphous fungus. Common signs include warty, ulcerated, crusty lesions on the face and limbs.

The disease peaks in middle age, but in Brazil nearly 6% of affected patients are children. Paracoccidioidomycosis is mainly a pulmonary infection, but it may disseminate to other organs.

The most common form, disseminated paracoccidioidomycosis, is characterized by pulmonary, mucocutaneous, and lymph node involvement. Oral lesions occur in 80% of adults with this form.

Skin lesions are usually painful ulcerative or verrucous plaques. He said he treats severe cases with amphotericin.

Eumycotic mycetoma of the foot is treated with surgery and long-term use of ketoconazole or itraconazole.

Localized sporotrichosis in a child is treated with itraconazole 5 mg/kg per day for 16 weeks. Photos courtesy Dr. Hector Caceres-Rios

SAN DIEGO — Most emergency department visits for influenza in the United States are by patients aged 5–49 years who have no other diagnoses, results from a large analysis have shown.

The finding underscores the importance of vaccination in this segment of the population, Kimmie Kohlhase McLaurin reported in a poster session at the 100th International Conference of the American Thoracic Society.

“We don't know much about influenza in this age group,” said Ms. McLaurin, a research analyst for MedImmune Inc., which manufactures FluMist, the intranasal vaccine that was approved in 2003 for healthy children and adults aged 5–49 years. “We know a lot more in the young and in the old. That's where our focus has been.”

In a study funded by MedImmune, Ms. McLaurin and her associate, Shelah Leader, Ph.D., analyzed emergency department data from the 1997–2002 National Hospital Ambulatory Medical Care Surveys to identify visits with a primary diagnosis of influenza based on ICD-9 codes 487.0 (influenza with pneumonia), 487.1 (influenza with other respiratory manifestations), and 487.8 (influenza with other manifestations). More than 1.1 million ED visits for influenza occurred during the 6-year study period. Of these, 69% were by patients aged 5–49 years.

Nearly three-quarters of ED visits by this age group (71%) had no secondary diagnoses, and visits were highest among 18–22-year-olds, nonwhites, and females.

January was noted to be the peak month for visits, followed by February, December, and March.

The most common procedures ordered by clinicians were CBC (35%), chest x-ray (26%), pulse oximetry (19%), and administration of IV fluids (14%).

Most visits (84%) resulted in prescriptions for analgesics (43%), cold/flu remedies (30%), and antibiotics (21%).

Reasons for the visit as reported by the patient were fever/chills (47%), cough (33%), myalgia (20%), throat symptoms (17%), flu (14%), vomiting (14%), and headache (12%).

Ms. McLaurin noted that the estimated direct medical costs of the ED visits during this time period were $576 million. The estimate was based on 1999 data published by the Medical Expenditure Panel Survey Household Component.

SAN DIEGO — Most emergency department visits for influenza in the United States are by patients aged 5–49 years who have no other diagnoses, results from a large analysis have shown.

The finding underscores the importance of vaccination in this segment of the population, Kimmie Kohlhase McLaurin reported in a poster session at the 100th International Conference of the American Thoracic Society.

“We don't know much about influenza in this age group,” said Ms. McLaurin, a research analyst for MedImmune Inc., which manufactures FluMist, the intranasal vaccine that was approved in 2003 for healthy children and adults aged 5–49 years. “We know a lot more in the young and in the old. That's where our focus has been.”

In a study funded by MedImmune, Ms. McLaurin and her associate, Shelah Leader, Ph.D., analyzed emergency department data from the 1997–2002 National Hospital Ambulatory Medical Care Surveys to identify visits with a primary diagnosis of influenza based on ICD-9 codes 487.0 (influenza with pneumonia), 487.1 (influenza with other respiratory manifestations), and 487.8 (influenza with other manifestations). More than 1.1 million ED visits for influenza occurred during the 6-year study period. Of these, 69% were by patients aged 5–49 years.

Nearly three-quarters of ED visits by this age group (71%) had no secondary diagnoses, and visits were highest among 18–22-year-olds, nonwhites, and females.

January was noted to be the peak month for visits, followed by February, December, and March.

The most common procedures ordered by clinicians were CBC (35%), chest x-ray (26%), pulse oximetry (19%), and administration of IV fluids (14%).

Most visits (84%) resulted in prescriptions for analgesics (43%), cold/flu remedies (30%), and antibiotics (21%).

Reasons for the visit as reported by the patient were fever/chills (47%), cough (33%), myalgia (20%), throat symptoms (17%), flu (14%), vomiting (14%), and headache (12%).

Ms. McLaurin noted that the estimated direct medical costs of the ED visits during this time period were $576 million. The estimate was based on 1999 data published by the Medical Expenditure Panel Survey Household Component.

SAN DIEGO — Most emergency department visits for influenza in the United States are by patients aged 5–49 years who have no other diagnoses, results from a large analysis have shown.

The finding underscores the importance of vaccination in this segment of the population, Kimmie Kohlhase McLaurin reported in a poster session at the 100th International Conference of the American Thoracic Society.

“We don't know much about influenza in this age group,” said Ms. McLaurin, a research analyst for MedImmune Inc., which manufactures FluMist, the intranasal vaccine that was approved in 2003 for healthy children and adults aged 5–49 years. “We know a lot more in the young and in the old. That's where our focus has been.”

In a study funded by MedImmune, Ms. McLaurin and her associate, Shelah Leader, Ph.D., analyzed emergency department data from the 1997–2002 National Hospital Ambulatory Medical Care Surveys to identify visits with a primary diagnosis of influenza based on ICD-9 codes 487.0 (influenza with pneumonia), 487.1 (influenza with other respiratory manifestations), and 487.8 (influenza with other manifestations). More than 1.1 million ED visits for influenza occurred during the 6-year study period. Of these, 69% were by patients aged 5–49 years.

Nearly three-quarters of ED visits by this age group (71%) had no secondary diagnoses, and visits were highest among 18–22-year-olds, nonwhites, and females.

January was noted to be the peak month for visits, followed by February, December, and March.

The most common procedures ordered by clinicians were CBC (35%), chest x-ray (26%), pulse oximetry (19%), and administration of IV fluids (14%).

Most visits (84%) resulted in prescriptions for analgesics (43%), cold/flu remedies (30%), and antibiotics (21%).

Reasons for the visit as reported by the patient were fever/chills (47%), cough (33%), myalgia (20%), throat symptoms (17%), flu (14%), vomiting (14%), and headache (12%).

Ms. McLaurin noted that the estimated direct medical costs of the ED visits during this time period were $576 million. The estimate was based on 1999 data published by the Medical Expenditure Panel Survey Household Component.

SAN DIEGO — Be vigilant about changes to the skin that suggest a diagnosis of Kawasaki disease in infants and children, Jane Burns, M.D., said at the annual meeting of the Society of Pediatric Dermatology.

“We don't want to miss the diagnosis,” said Dr. Burns, who directs the Kawasaki Disease Research Program at the University of California, San Diego. “The clinical signs come and go. We have to rely on history in order to establish the diagnosis in these patients, so a criterion that was present historically is just as valid as a criterion that you can actually see in front of you. Clearly this is dynamic, and different kids evolve in a different kind of rhythm. But historical presence of one of these clinical findings should be taken seriously.”

Skin-related signs of Kawasaki disease (KD) may include:

▸ Bilateral, nonexudative dilation of conjunctival vessels. This presents as a dry eye with dilated vessels and limbal sparing. “The reason that we see the limbus so clearly is that there is no edema in the conjunctiva,” she explained. “This is not conjunctivitis. That is a misnomer. This is vessel dilatation, probably mediated by cytokines and other factors. These are simply dilated vessels. We've done conjunctival biopsies on these children and that's what we see.”

She added that the condition is marked by no tearing, no superficial infection or involvement of the epithelial cells. “This is not like adenovirus,” she said. “There is no inflammation on the outside of the eye.”

▸ Erythema of lips.

▸ Classic “strawberry tongue.” This presents as a sloughing of the filiform papillae because of the systemic inflammatory process and persistence of the fungiform papillae, which gives the appearance of strawberry “seeds.” Strawberry tongue is also associated with streptococcal and staphylococcal diseases. “It's not pathognomonic for KD, but it's a helpful finding when you see it,” Dr. Burns said.

▸ Accentuated groin rash. This symptom is seen in about half of KD patients. “Pediatricians frequently mistake this for diaper dermatitis,” she said. “Desquamation occurs during the acute phase of the disease.”

▸ Unilaterally enlarged lymph node. Fewer than 40% of KD patients will present with this symptom. “Generally it's a unilateral anterior cervical node, usually involving the jugular digastric node,” Dr. Burns said. “These are the patients that get referred to ENT. Hopefully they recognize it, but unfortunately many times these kids are treated for bacterial lymphadenitis. Then they develop a rash. The rash is thought to be related to the antibiotic therapy, and [the rash persists] until someone recognizes what's going on.”

▸ Micropustular rash with petechiae. Although this rash only presents in about 15% of KD patients, it's very specific for the disease. It typically presents over the buttocks and sometimes on the extensor surfaces of the arms.

▸ Diffuse erythema of the palm. “There is no pattern to the erythema,” Dr. Burns said of this symptom. “It comes and goes during the course of the disease.”

▸ Diffuse erythema of the sole.

▸ Swelling of the hands and feet.

Eczema is another complication that affects children with KD. “They may present with their first exacerbation of eczema in the convalescent period of the disease,” she said. “Then there's psoriasis. This can happen within 2 months of the onset.”

Although there are no specific diagnostic tests for KD, Dr. Burns noted that nonspecific indicators of inflammation—such as C-reactive protein and sedimentation rate—are elevated. She added that gamma-glutamyl-transferase “is a very useful marker of hepatobiliary dysfunction [in KD patients], not typically seen in a lot of other viral infections.”

For a diagnostic algorithm of Kawasaki disease, Dr. Burns suggested referring to the following journal article: Circulation 2004;110:2747–71.

SAN DIEGO — Be vigilant about changes to the skin that suggest a diagnosis of Kawasaki disease in infants and children, Jane Burns, M.D., said at the annual meeting of the Society of Pediatric Dermatology.

“We don't want to miss the diagnosis,” said Dr. Burns, who directs the Kawasaki Disease Research Program at the University of California, San Diego. “The clinical signs come and go. We have to rely on history in order to establish the diagnosis in these patients, so a criterion that was present historically is just as valid as a criterion that you can actually see in front of you. Clearly this is dynamic, and different kids evolve in a different kind of rhythm. But historical presence of one of these clinical findings should be taken seriously.”

Skin-related signs of Kawasaki disease (KD) may include:

▸ Bilateral, nonexudative dilation of conjunctival vessels. This presents as a dry eye with dilated vessels and limbal sparing. “The reason that we see the limbus so clearly is that there is no edema in the conjunctiva,” she explained. “This is not conjunctivitis. That is a misnomer. This is vessel dilatation, probably mediated by cytokines and other factors. These are simply dilated vessels. We've done conjunctival biopsies on these children and that's what we see.”

She added that the condition is marked by no tearing, no superficial infection or involvement of the epithelial cells. “This is not like adenovirus,” she said. “There is no inflammation on the outside of the eye.”

▸ Erythema of lips.

▸ Classic “strawberry tongue.” This presents as a sloughing of the filiform papillae because of the systemic inflammatory process and persistence of the fungiform papillae, which gives the appearance of strawberry “seeds.” Strawberry tongue is also associated with streptococcal and staphylococcal diseases. “It's not pathognomonic for KD, but it's a helpful finding when you see it,” Dr. Burns said.

▸ Accentuated groin rash. This symptom is seen in about half of KD patients. “Pediatricians frequently mistake this for diaper dermatitis,” she said. “Desquamation occurs during the acute phase of the disease.”

▸ Unilaterally enlarged lymph node. Fewer than 40% of KD patients will present with this symptom. “Generally it's a unilateral anterior cervical node, usually involving the jugular digastric node,” Dr. Burns said. “These are the patients that get referred to ENT. Hopefully they recognize it, but unfortunately many times these kids are treated for bacterial lymphadenitis. Then they develop a rash. The rash is thought to be related to the antibiotic therapy, and [the rash persists] until someone recognizes what's going on.”

▸ Micropustular rash with petechiae. Although this rash only presents in about 15% of KD patients, it's very specific for the disease. It typically presents over the buttocks and sometimes on the extensor surfaces of the arms.

▸ Diffuse erythema of the palm. “There is no pattern to the erythema,” Dr. Burns said of this symptom. “It comes and goes during the course of the disease.”

▸ Diffuse erythema of the sole.

▸ Swelling of the hands and feet.

Eczema is another complication that affects children with KD. “They may present with their first exacerbation of eczema in the convalescent period of the disease,” she said. “Then there's psoriasis. This can happen within 2 months of the onset.”

Although there are no specific diagnostic tests for KD, Dr. Burns noted that nonspecific indicators of inflammation—such as C-reactive protein and sedimentation rate—are elevated. She added that gamma-glutamyl-transferase “is a very useful marker of hepatobiliary dysfunction [in KD patients], not typically seen in a lot of other viral infections.”

For a diagnostic algorithm of Kawasaki disease, Dr. Burns suggested referring to the following journal article: Circulation 2004;110:2747–71.

SAN DIEGO — Be vigilant about changes to the skin that suggest a diagnosis of Kawasaki disease in infants and children, Jane Burns, M.D., said at the annual meeting of the Society of Pediatric Dermatology.

“We don't want to miss the diagnosis,” said Dr. Burns, who directs the Kawasaki Disease Research Program at the University of California, San Diego. “The clinical signs come and go. We have to rely on history in order to establish the diagnosis in these patients, so a criterion that was present historically is just as valid as a criterion that you can actually see in front of you. Clearly this is dynamic, and different kids evolve in a different kind of rhythm. But historical presence of one of these clinical findings should be taken seriously.”

Skin-related signs of Kawasaki disease (KD) may include:

▸ Bilateral, nonexudative dilation of conjunctival vessels. This presents as a dry eye with dilated vessels and limbal sparing. “The reason that we see the limbus so clearly is that there is no edema in the conjunctiva,” she explained. “This is not conjunctivitis. That is a misnomer. This is vessel dilatation, probably mediated by cytokines and other factors. These are simply dilated vessels. We've done conjunctival biopsies on these children and that's what we see.”

She added that the condition is marked by no tearing, no superficial infection or involvement of the epithelial cells. “This is not like adenovirus,” she said. “There is no inflammation on the outside of the eye.”

▸ Erythema of lips.

▸ Classic “strawberry tongue.” This presents as a sloughing of the filiform papillae because of the systemic inflammatory process and persistence of the fungiform papillae, which gives the appearance of strawberry “seeds.” Strawberry tongue is also associated with streptococcal and staphylococcal diseases. “It's not pathognomonic for KD, but it's a helpful finding when you see it,” Dr. Burns said.

▸ Accentuated groin rash. This symptom is seen in about half of KD patients. “Pediatricians frequently mistake this for diaper dermatitis,” she said. “Desquamation occurs during the acute phase of the disease.”

▸ Unilaterally enlarged lymph node. Fewer than 40% of KD patients will present with this symptom. “Generally it's a unilateral anterior cervical node, usually involving the jugular digastric node,” Dr. Burns said. “These are the patients that get referred to ENT. Hopefully they recognize it, but unfortunately many times these kids are treated for bacterial lymphadenitis. Then they develop a rash. The rash is thought to be related to the antibiotic therapy, and [the rash persists] until someone recognizes what's going on.”

▸ Micropustular rash with petechiae. Although this rash only presents in about 15% of KD patients, it's very specific for the disease. It typically presents over the buttocks and sometimes on the extensor surfaces of the arms.

▸ Diffuse erythema of the palm. “There is no pattern to the erythema,” Dr. Burns said of this symptom. “It comes and goes during the course of the disease.”

▸ Diffuse erythema of the sole.

▸ Swelling of the hands and feet.

Eczema is another complication that affects children with KD. “They may present with their first exacerbation of eczema in the convalescent period of the disease,” she said. “Then there's psoriasis. This can happen within 2 months of the onset.”

Although there are no specific diagnostic tests for KD, Dr. Burns noted that nonspecific indicators of inflammation—such as C-reactive protein and sedimentation rate—are elevated. She added that gamma-glutamyl-transferase “is a very useful marker of hepatobiliary dysfunction [in KD patients], not typically seen in a lot of other viral infections.”

For a diagnostic algorithm of Kawasaki disease, Dr. Burns suggested referring to the following journal article: Circulation 2004;110:2747–71.

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

SAN DIEGO — Older adults with diabetes are more likely to have poor muscle quality and accelerated loss of strength over a 3-year period, compared with their peers who don't have the disease, Seok Won Park, M.D., reported at the annual scientific sessions of the American Diabetes Association.

“These characteristics may contribute to the development of physical disability in older adults with diabetes,” said Dr. Park, an epidemiologist at the University of Pittsburgh.

Although it is known that older adults with diabetes face a two- to threefold higher risk of physical disability, this increased risk has not been studied with regard to changes in muscle characteristics, such as strength.

Dr. Park and his associates used an isokinetic dynamometer to evaluate knee extensor strength and used dual-energy x-ray absorptiometry (DXA) to measure muscle mass in a cohort of 1,863 men and women with a mean age of 74 who were enrolled in the Health, Aging, and Body Composition Study sponsored by the National Institute on Aging. Study participants returned for follow-up evaluations 3 years later.

The researchers defined muscle quality as muscle strength per unit of regional muscle mass in kilograms.

Baseline measurements revealed that older adults with diabetes had greater leg muscle mass than controls, but knee extensor strength was lower in diabetic men, compared with men in the control group.

Among women, absolute strength at baseline did not differ by diabetes status, but muscle quality was significantly lower in women with diabetes, compared with controls. This was also the case for men with diabetes.

At 3 years, men and women with diabetes showed a more rapid decline in muscle mass, compared with controls. This greater loss of leg muscle mass among older men and women with diabetes accounted for some of the loss of strength over the 3-year period, but they also had a larger decline in muscle quality, compared with controls, Dr. Park noted.

The results remained similar after the researchers adjusted for sex, age, race, combined chronic disease, smoking, alcohol consumption, and level of physical activity.

SAN DIEGO — Older adults with diabetes are more likely to have poor muscle quality and accelerated loss of strength over a 3-year period, compared with their peers who don't have the disease, Seok Won Park, M.D., reported at the annual scientific sessions of the American Diabetes Association.

“These characteristics may contribute to the development of physical disability in older adults with diabetes,” said Dr. Park, an epidemiologist at the University of Pittsburgh.

Although it is known that older adults with diabetes face a two- to threefold higher risk of physical disability, this increased risk has not been studied with regard to changes in muscle characteristics, such as strength.

Dr. Park and his associates used an isokinetic dynamometer to evaluate knee extensor strength and used dual-energy x-ray absorptiometry (DXA) to measure muscle mass in a cohort of 1,863 men and women with a mean age of 74 who were enrolled in the Health, Aging, and Body Composition Study sponsored by the National Institute on Aging. Study participants returned for follow-up evaluations 3 years later.

The researchers defined muscle quality as muscle strength per unit of regional muscle mass in kilograms.

Baseline measurements revealed that older adults with diabetes had greater leg muscle mass than controls, but knee extensor strength was lower in diabetic men, compared with men in the control group.

Among women, absolute strength at baseline did not differ by diabetes status, but muscle quality was significantly lower in women with diabetes, compared with controls. This was also the case for men with diabetes.

At 3 years, men and women with diabetes showed a more rapid decline in muscle mass, compared with controls. This greater loss of leg muscle mass among older men and women with diabetes accounted for some of the loss of strength over the 3-year period, but they also had a larger decline in muscle quality, compared with controls, Dr. Park noted.

The results remained similar after the researchers adjusted for sex, age, race, combined chronic disease, smoking, alcohol consumption, and level of physical activity.

SAN DIEGO — Older adults with diabetes are more likely to have poor muscle quality and accelerated loss of strength over a 3-year period, compared with their peers who don't have the disease, Seok Won Park, M.D., reported at the annual scientific sessions of the American Diabetes Association.

“These characteristics may contribute to the development of physical disability in older adults with diabetes,” said Dr. Park, an epidemiologist at the University of Pittsburgh.

Although it is known that older adults with diabetes face a two- to threefold higher risk of physical disability, this increased risk has not been studied with regard to changes in muscle characteristics, such as strength.

Dr. Park and his associates used an isokinetic dynamometer to evaluate knee extensor strength and used dual-energy x-ray absorptiometry (DXA) to measure muscle mass in a cohort of 1,863 men and women with a mean age of 74 who were enrolled in the Health, Aging, and Body Composition Study sponsored by the National Institute on Aging. Study participants returned for follow-up evaluations 3 years later.

The researchers defined muscle quality as muscle strength per unit of regional muscle mass in kilograms.

Baseline measurements revealed that older adults with diabetes had greater leg muscle mass than controls, but knee extensor strength was lower in diabetic men, compared with men in the control group.

Among women, absolute strength at baseline did not differ by diabetes status, but muscle quality was significantly lower in women with diabetes, compared with controls. This was also the case for men with diabetes.

At 3 years, men and women with diabetes showed a more rapid decline in muscle mass, compared with controls. This greater loss of leg muscle mass among older men and women with diabetes accounted for some of the loss of strength over the 3-year period, but they also had a larger decline in muscle quality, compared with controls, Dr. Park noted.

The results remained similar after the researchers adjusted for sex, age, race, combined chronic disease, smoking, alcohol consumption, and level of physical activity.

SAN DIEGO — Initiating treatment with pimecrolimus cream 1% during the early signs of atopic dermatitis in infants and children significantly reduced the incidence of flares, prolonged flare-free intervals, and reduced the need for a topical corticosteroid, Elaine Siegfried, M.D., reported during a poster session at the annual meeting of the Society for Pediatric Dermatology.

“This is a straightforward study that reflects what people experience in their practices,” Dr. Siegfried told FAMILY PRACTICE NEWS. “When you use a steroid-sparing agent like topical pimecrolimus in combination with a steroid, it helps reduce the need for steroid and helps kids get under better control. There were no safety blips.”

In what she identified as the first study of its kind, Dr. Siegfried and her associates randomized 275 infants and children aged 3 months to 11 years with mild to moderate atopic dermatitis 2:1 to receive pimecrolimus cream 1% or a control vehicle used to maintain blinding. Bland emollients were applied for dry skin in both treatment groups.

Over a 6-month period, pimecrolimus or vehicle was applied twice daily at first signs and symptoms of atopic dermatitis and continued until resolution or major flare, which was defined as an investigators' global assessment score of 4 or 5. Major flares were treated with the study drug once daily in the morning and with a midpotent corticosteroid once daily in the evening until resolution, or for a maximum of 3 weeks.

More than half of the patients in the pimecrolimus group (52%) did not experience a single flare, compared with 34% of patients in the control group, reported Dr. Siegfried, a pediatric dermatologist who practices in St. Louis. Only 7% of patients in the pimecrolimus group experienced more than two flares, compared with 23% of controls.

Among study participants who experienced a flare, the time to onset of first and second flare was significantly delayed among those in the pimecrolimus group, compared with controls (55 days vs. 22 days and 44 days vs. 26 days, respectively).

In addition, improvement in pruritus occurred significantly sooner among patients in the pimecrolimus group, compared with controls (a median of 3 days vs. a median of 5 days, respectively), and patients in the pimecrolimus group were exposed to topical corticosteroid for a significantly shorter time, compared with controls (a mean of 11 days vs. a mean of 17 days, respectively).

As for safety, “most adverse events represented typical childhood illness of mild to moderate severity,” the investigators wrote in their poster.

A burning sensation at the application site was the most common adverse event reported (2.2% for patients in both treatment groups).

Novartis Pharmaceuticals Corp. funded the study.

In a related Novartis-sponsored poster presented at the meeting, Joseph Fowler, M.D., and his associates found that children who used pimecrolimus 1% for their atopic dermatitis experienced significant improvement of their pruritus by day 2 of treatment.

For the 7-day study, 174 children aged 2–17 years with mild to moderate atopic dermatitis were randomized to receive pimecrolimus cream 1% twice daily or a control vehicle cream.

“On the second day of pimecrolimus cream 1% treatment, pediatric patients with mild to moderate atopic dermatitis and moderate to severe pruritus experienced significant improvement in their pruritus,” the investigators wrote in their poster.

“As early as day 3 following initiation of pimecrolimus, significantly more pediatric patients in the pimecrolimus-treatment group experienced complete resolution of pruritus, with 37% of pimecrolimus-treated patients free of pruritus by day 7,” they wrote.

Dr. Fowler practices in Louisville, Ky.

SAN DIEGO — Initiating treatment with pimecrolimus cream 1% during the early signs of atopic dermatitis in infants and children significantly reduced the incidence of flares, prolonged flare-free intervals, and reduced the need for a topical corticosteroid, Elaine Siegfried, M.D., reported during a poster session at the annual meeting of the Society for Pediatric Dermatology.

“This is a straightforward study that reflects what people experience in their practices,” Dr. Siegfried told FAMILY PRACTICE NEWS. “When you use a steroid-sparing agent like topical pimecrolimus in combination with a steroid, it helps reduce the need for steroid and helps kids get under better control. There were no safety blips.”

In what she identified as the first study of its kind, Dr. Siegfried and her associates randomized 275 infants and children aged 3 months to 11 years with mild to moderate atopic dermatitis 2:1 to receive pimecrolimus cream 1% or a control vehicle used to maintain blinding. Bland emollients were applied for dry skin in both treatment groups.

Over a 6-month period, pimecrolimus or vehicle was applied twice daily at first signs and symptoms of atopic dermatitis and continued until resolution or major flare, which was defined as an investigators' global assessment score of 4 or 5. Major flares were treated with the study drug once daily in the morning and with a midpotent corticosteroid once daily in the evening until resolution, or for a maximum of 3 weeks.

More than half of the patients in the pimecrolimus group (52%) did not experience a single flare, compared with 34% of patients in the control group, reported Dr. Siegfried, a pediatric dermatologist who practices in St. Louis. Only 7% of patients in the pimecrolimus group experienced more than two flares, compared with 23% of controls.

Among study participants who experienced a flare, the time to onset of first and second flare was significantly delayed among those in the pimecrolimus group, compared with controls (55 days vs. 22 days and 44 days vs. 26 days, respectively).

In addition, improvement in pruritus occurred significantly sooner among patients in the pimecrolimus group, compared with controls (a median of 3 days vs. a median of 5 days, respectively), and patients in the pimecrolimus group were exposed to topical corticosteroid for a significantly shorter time, compared with controls (a mean of 11 days vs. a mean of 17 days, respectively).

As for safety, “most adverse events represented typical childhood illness of mild to moderate severity,” the investigators wrote in their poster.

A burning sensation at the application site was the most common adverse event reported (2.2% for patients in both treatment groups).

Novartis Pharmaceuticals Corp. funded the study.

In a related Novartis-sponsored poster presented at the meeting, Joseph Fowler, M.D., and his associates found that children who used pimecrolimus 1% for their atopic dermatitis experienced significant improvement of their pruritus by day 2 of treatment.

For the 7-day study, 174 children aged 2–17 years with mild to moderate atopic dermatitis were randomized to receive pimecrolimus cream 1% twice daily or a control vehicle cream.

“On the second day of pimecrolimus cream 1% treatment, pediatric patients with mild to moderate atopic dermatitis and moderate to severe pruritus experienced significant improvement in their pruritus,” the investigators wrote in their poster.

“As early as day 3 following initiation of pimecrolimus, significantly more pediatric patients in the pimecrolimus-treatment group experienced complete resolution of pruritus, with 37% of pimecrolimus-treated patients free of pruritus by day 7,” they wrote.

Dr. Fowler practices in Louisville, Ky.

SAN DIEGO — Initiating treatment with pimecrolimus cream 1% during the early signs of atopic dermatitis in infants and children significantly reduced the incidence of flares, prolonged flare-free intervals, and reduced the need for a topical corticosteroid, Elaine Siegfried, M.D., reported during a poster session at the annual meeting of the Society for Pediatric Dermatology.

“This is a straightforward study that reflects what people experience in their practices,” Dr. Siegfried told FAMILY PRACTICE NEWS. “When you use a steroid-sparing agent like topical pimecrolimus in combination with a steroid, it helps reduce the need for steroid and helps kids get under better control. There were no safety blips.”

In what she identified as the first study of its kind, Dr. Siegfried and her associates randomized 275 infants and children aged 3 months to 11 years with mild to moderate atopic dermatitis 2:1 to receive pimecrolimus cream 1% or a control vehicle used to maintain blinding. Bland emollients were applied for dry skin in both treatment groups.

Over a 6-month period, pimecrolimus or vehicle was applied twice daily at first signs and symptoms of atopic dermatitis and continued until resolution or major flare, which was defined as an investigators' global assessment score of 4 or 5. Major flares were treated with the study drug once daily in the morning and with a midpotent corticosteroid once daily in the evening until resolution, or for a maximum of 3 weeks.

More than half of the patients in the pimecrolimus group (52%) did not experience a single flare, compared with 34% of patients in the control group, reported Dr. Siegfried, a pediatric dermatologist who practices in St. Louis. Only 7% of patients in the pimecrolimus group experienced more than two flares, compared with 23% of controls.

Among study participants who experienced a flare, the time to onset of first and second flare was significantly delayed among those in the pimecrolimus group, compared with controls (55 days vs. 22 days and 44 days vs. 26 days, respectively).

In addition, improvement in pruritus occurred significantly sooner among patients in the pimecrolimus group, compared with controls (a median of 3 days vs. a median of 5 days, respectively), and patients in the pimecrolimus group were exposed to topical corticosteroid for a significantly shorter time, compared with controls (a mean of 11 days vs. a mean of 17 days, respectively).

As for safety, “most adverse events represented typical childhood illness of mild to moderate severity,” the investigators wrote in their poster.

A burning sensation at the application site was the most common adverse event reported (2.2% for patients in both treatment groups).

Novartis Pharmaceuticals Corp. funded the study.

In a related Novartis-sponsored poster presented at the meeting, Joseph Fowler, M.D., and his associates found that children who used pimecrolimus 1% for their atopic dermatitis experienced significant improvement of their pruritus by day 2 of treatment.

For the 7-day study, 174 children aged 2–17 years with mild to moderate atopic dermatitis were randomized to receive pimecrolimus cream 1% twice daily or a control vehicle cream.

“On the second day of pimecrolimus cream 1% treatment, pediatric patients with mild to moderate atopic dermatitis and moderate to severe pruritus experienced significant improvement in their pruritus,” the investigators wrote in their poster.

“As early as day 3 following initiation of pimecrolimus, significantly more pediatric patients in the pimecrolimus-treatment group experienced complete resolution of pruritus, with 37% of pimecrolimus-treated patients free of pruritus by day 7,” they wrote.

Dr. Fowler practices in Louisville, Ky.

SAN DIEGO — The most aggressive variant of Langerhans cell histiocytosis, Letterer-Siwe disease is characterized by cutaneous involvement, organo-megaly, and thrombocytopenia, Joseph P. Janik, M.D., said during a poster session at the annual meeting of the Society for Pediatric Dermatology.

The patient was thrombocytopenic and had an enlarged spleen and liver, but there were no lung abnormalities. The results of two shave biopsies confirmed the diagnosis, said Dr. Janik, the lead author of the case report, of the department of dermatology at the University of New Mexico, Albuquerque.

Few controlled studies exist for the treatment of the Letterer-Siwe variant of Langerhans cell histiocytosis, let alone the congenital form. PUVA and topical nitrogen mustard seem to be most effective for the skin lesions while vinblastine or etoposide have been used for the systemic manifestations (J. Pediatr. 1991; 119:317–21). For nonresponders, a combination chemotherapy can be tried.

The response rate to monochemotherapy can reach 90%, but the overall outcome is usually fatal, especially in the congenital form of Letterer-Siwe (Cancer 1988;62:2528–31). At press time, this patient is alive at the age of 21 months, after a year of treatment with vinblastine, prednisone, and 6-mercaptopurine.

Dr. Janik discussed another case of the Letterer-Siwe variant of congenital Langerhans cell histiocytosis in a baby born at 28 weeks' gestation. Apgar scores for the baby, who was delivered via emergent C-section, were 2 at 1 minute, 1 at 5 minutes, and 1 at 10 minutes. Resuscitation attempts were unsuccessful, and the baby expired 25 minutes after birth.

Ran H. Bang, M.D., Charles H. Palmer, M.D., E. Ben Smith, M.D., and R. Steven Padilla, M.D., all of University of New Mexico, assisted with the case reports.

SAN DIEGO — The most aggressive variant of Langerhans cell histiocytosis, Letterer-Siwe disease is characterized by cutaneous involvement, organo-megaly, and thrombocytopenia, Joseph P. Janik, M.D., said during a poster session at the annual meeting of the Society for Pediatric Dermatology.

The patient was thrombocytopenic and had an enlarged spleen and liver, but there were no lung abnormalities. The results of two shave biopsies confirmed the diagnosis, said Dr. Janik, the lead author of the case report, of the department of dermatology at the University of New Mexico, Albuquerque.

Few controlled studies exist for the treatment of the Letterer-Siwe variant of Langerhans cell histiocytosis, let alone the congenital form. PUVA and topical nitrogen mustard seem to be most effective for the skin lesions while vinblastine or etoposide have been used for the systemic manifestations (J. Pediatr. 1991; 119:317–21). For nonresponders, a combination chemotherapy can be tried.

The response rate to monochemotherapy can reach 90%, but the overall outcome is usually fatal, especially in the congenital form of Letterer-Siwe (Cancer 1988;62:2528–31). At press time, this patient is alive at the age of 21 months, after a year of treatment with vinblastine, prednisone, and 6-mercaptopurine.

Dr. Janik discussed another case of the Letterer-Siwe variant of congenital Langerhans cell histiocytosis in a baby born at 28 weeks' gestation. Apgar scores for the baby, who was delivered via emergent C-section, were 2 at 1 minute, 1 at 5 minutes, and 1 at 10 minutes. Resuscitation attempts were unsuccessful, and the baby expired 25 minutes after birth.

Ran H. Bang, M.D., Charles H. Palmer, M.D., E. Ben Smith, M.D., and R. Steven Padilla, M.D., all of University of New Mexico, assisted with the case reports.

SAN DIEGO — The most aggressive variant of Langerhans cell histiocytosis, Letterer-Siwe disease is characterized by cutaneous involvement, organo-megaly, and thrombocytopenia, Joseph P. Janik, M.D., said during a poster session at the annual meeting of the Society for Pediatric Dermatology.

The patient was thrombocytopenic and had an enlarged spleen and liver, but there were no lung abnormalities. The results of two shave biopsies confirmed the diagnosis, said Dr. Janik, the lead author of the case report, of the department of dermatology at the University of New Mexico, Albuquerque.

Few controlled studies exist for the treatment of the Letterer-Siwe variant of Langerhans cell histiocytosis, let alone the congenital form. PUVA and topical nitrogen mustard seem to be most effective for the skin lesions while vinblastine or etoposide have been used for the systemic manifestations (J. Pediatr. 1991; 119:317–21). For nonresponders, a combination chemotherapy can be tried.

The response rate to monochemotherapy can reach 90%, but the overall outcome is usually fatal, especially in the congenital form of Letterer-Siwe (Cancer 1988;62:2528–31). At press time, this patient is alive at the age of 21 months, after a year of treatment with vinblastine, prednisone, and 6-mercaptopurine.

Dr. Janik discussed another case of the Letterer-Siwe variant of congenital Langerhans cell histiocytosis in a baby born at 28 weeks' gestation. Apgar scores for the baby, who was delivered via emergent C-section, were 2 at 1 minute, 1 at 5 minutes, and 1 at 10 minutes. Resuscitation attempts were unsuccessful, and the baby expired 25 minutes after birth.

Ran H. Bang, M.D., Charles H. Palmer, M.D., E. Ben Smith, M.D., and R. Steven Padilla, M.D., all of University of New Mexico, assisted with the case reports.