Jeff Evans

Prophylactic surgery may help to prevent gynecologic cancers in women with hereditary nonpolyposis colorectal cancer, reported Dr. Kathleen M. Schmeler of the University of Texas M.D. Anderson Cancer Center, Houston, and her associates.

In a retrospective study of a cohort of patients who had germ-line mutations associated with hereditary nonpolyposis colorectal cancer (Lynch syndrome), significantly fewer endometrial cancers occurred in women who had a prophylactic hysterectomy (0 of 61) than in those who did not (69 of 210).

None of the 47 women who had undergone a bilateral salpingo-oophorectomy for cancer prevention or benign conditions at the same time as their hysterectomy developed ovarian cancer, but this was not significantly different from the number of women in the control group who developed ovarian cancer (12 of 223).

The women underwent hysterectomy or bilateral salpingo-oophorectomy at a median age of 41 years, whereas the median age at diagnosis was 46 years for endometrial cancer and 42 years for ovarian cancer.

All but four of the endometrial and two of the ovarian cancers occurred in women older than 35 years, according to the investigators (N. Engl. J. Med. 2006;354:261–9).

“These findings support consideration of prophylactic hysterectomy and bilateral salpingo-oophorectomy in women with the Lynch syndrome after the age of 35, or once childbearing has been completed,” Dr. Schmeler and her colleagues wrote. Only one complication (ureteral injury and repair) occurred in the 61 women patients who underwent prophylactic surgery.

Of the 107 women in the cohort who had colorectal cancer, endometrial or ovarian cancer occurred synchronously with colorectal cancer in 3 patients and at different times in 38 patients.

In 21 of those patients, gynecologic cancer was diagnosed a median of 5 years after they were diagnosed with and underwent surgery for colorectal cancer.

The gynecologic cancer that occurred in that subgroup of 21 women “could have been prevented if prophylactic hysterectomy and bilateral salpingo-oophorectomy had been performed at the time of surgery for colorectal cancer,” the investigators noted.

“Preoperative counseling should address the trade-offs between the reduction in the risk of cancer and the risks and side effects of surgery, as well as the uncertainties regarding surveillance of gynecologic cancer as an alternative management approach,” the researchers concluded.

Prophylactic surgery may help to prevent gynecologic cancers in women with hereditary nonpolyposis colorectal cancer, reported Dr. Kathleen M. Schmeler of the University of Texas M.D. Anderson Cancer Center, Houston, and her associates.

In a retrospective study of a cohort of patients who had germ-line mutations associated with hereditary nonpolyposis colorectal cancer (Lynch syndrome), significantly fewer endometrial cancers occurred in women who had a prophylactic hysterectomy (0 of 61) than in those who did not (69 of 210).

None of the 47 women who had undergone a bilateral salpingo-oophorectomy for cancer prevention or benign conditions at the same time as their hysterectomy developed ovarian cancer, but this was not significantly different from the number of women in the control group who developed ovarian cancer (12 of 223).

The women underwent hysterectomy or bilateral salpingo-oophorectomy at a median age of 41 years, whereas the median age at diagnosis was 46 years for endometrial cancer and 42 years for ovarian cancer.

All but four of the endometrial and two of the ovarian cancers occurred in women older than 35 years, according to the investigators (N. Engl. J. Med. 2006;354:261–9).

“These findings support consideration of prophylactic hysterectomy and bilateral salpingo-oophorectomy in women with the Lynch syndrome after the age of 35, or once childbearing has been completed,” Dr. Schmeler and her colleagues wrote. Only one complication (ureteral injury and repair) occurred in the 61 women patients who underwent prophylactic surgery.

Of the 107 women in the cohort who had colorectal cancer, endometrial or ovarian cancer occurred synchronously with colorectal cancer in 3 patients and at different times in 38 patients.

In 21 of those patients, gynecologic cancer was diagnosed a median of 5 years after they were diagnosed with and underwent surgery for colorectal cancer.

The gynecologic cancer that occurred in that subgroup of 21 women “could have been prevented if prophylactic hysterectomy and bilateral salpingo-oophorectomy had been performed at the time of surgery for colorectal cancer,” the investigators noted.

“Preoperative counseling should address the trade-offs between the reduction in the risk of cancer and the risks and side effects of surgery, as well as the uncertainties regarding surveillance of gynecologic cancer as an alternative management approach,” the researchers concluded.

Prophylactic surgery may help to prevent gynecologic cancers in women with hereditary nonpolyposis colorectal cancer, reported Dr. Kathleen M. Schmeler of the University of Texas M.D. Anderson Cancer Center, Houston, and her associates.

In a retrospective study of a cohort of patients who had germ-line mutations associated with hereditary nonpolyposis colorectal cancer (Lynch syndrome), significantly fewer endometrial cancers occurred in women who had a prophylactic hysterectomy (0 of 61) than in those who did not (69 of 210).

None of the 47 women who had undergone a bilateral salpingo-oophorectomy for cancer prevention or benign conditions at the same time as their hysterectomy developed ovarian cancer, but this was not significantly different from the number of women in the control group who developed ovarian cancer (12 of 223).

The women underwent hysterectomy or bilateral salpingo-oophorectomy at a median age of 41 years, whereas the median age at diagnosis was 46 years for endometrial cancer and 42 years for ovarian cancer.

All but four of the endometrial and two of the ovarian cancers occurred in women older than 35 years, according to the investigators (N. Engl. J. Med. 2006;354:261–9).

“These findings support consideration of prophylactic hysterectomy and bilateral salpingo-oophorectomy in women with the Lynch syndrome after the age of 35, or once childbearing has been completed,” Dr. Schmeler and her colleagues wrote. Only one complication (ureteral injury and repair) occurred in the 61 women patients who underwent prophylactic surgery.

Of the 107 women in the cohort who had colorectal cancer, endometrial or ovarian cancer occurred synchronously with colorectal cancer in 3 patients and at different times in 38 patients.

In 21 of those patients, gynecologic cancer was diagnosed a median of 5 years after they were diagnosed with and underwent surgery for colorectal cancer.

The gynecologic cancer that occurred in that subgroup of 21 women “could have been prevented if prophylactic hysterectomy and bilateral salpingo-oophorectomy had been performed at the time of surgery for colorectal cancer,” the investigators noted.

“Preoperative counseling should address the trade-offs between the reduction in the risk of cancer and the risks and side effects of surgery, as well as the uncertainties regarding surveillance of gynecologic cancer as an alternative management approach,” the researchers concluded.

NEW YORK — Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate, said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, have a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake while on stimulants. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight, and children who use sustained-release formulations.

Dr. Carlson advised obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months while on treatment. A decrease of more than one standard deviation in height for age while on treatment should prompt consultation to exclude other disorders.

NEW YORK — Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate, said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, have a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake while on stimulants. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight, and children who use sustained-release formulations.

Dr. Carlson advised obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months while on treatment. A decrease of more than one standard deviation in height for age while on treatment should prompt consultation to exclude other disorders.

NEW YORK — Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate, said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, have a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake while on stimulants. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight, and children who use sustained-release formulations.

Dr. Carlson advised obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months while on treatment. A decrease of more than one standard deviation in height for age while on treatment should prompt consultation to exclude other disorders.

BETHESDA, MD. — Treatment for substance use disorders continues to be out of reach for many people who need it at a time in which funding for treatment and health plan coverage of substance abuse remains stagnate, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University, Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%). Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting—1.8% of all health care expenditures—came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003. The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%.

BETHESDA, MD. — Treatment for substance use disorders continues to be out of reach for many people who need it at a time in which funding for treatment and health plan coverage of substance abuse remains stagnate, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University, Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%). Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting—1.8% of all health care expenditures—came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003. The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%.

BETHESDA, MD. — Treatment for substance use disorders continues to be out of reach for many people who need it at a time in which funding for treatment and health plan coverage of substance abuse remains stagnate, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University, Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%). Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting—1.8% of all health care expenditures—came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003. The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%.

Recognition of the early meningococcal disease features of leg pain, cold hands and feet, and abnormal skin color may help get children to the hospital faster than classic symptoms that occur later in the illness, reported Dr. Matthew J. Thompson of the University of Oxford (England) and his associates.

The information about early symptoms came from a retrospective study that provides the first description of the time course of clinical features of meningococcal disease that occur before hospital admission, they said (Lancet 2006 Jan. 11 [Epub doi:10.1016/S0140-6736(06)67932-4]).

Meningococcal disease is typically diagnosed in children at presentation to a hospital after the onset of late-occurring classic symptoms, which include hemorrhagic rash, meningism, and impaired consciousness.

“We believe that primary care physicians are overreliant on using these three [classic] symptoms to diagnose meningococcal disease in children, and that parents may be influenced by doctors or public health campaigns to seek medical advice only on the appearance of features such as a rapidly evolving rash,” according to Dr. Thompson and his associates.

But Dr. Keith S. Reisinger, a pediatrician in private practice in Pittsburgh, contended that these early symptoms “are not specific enough to alarm a parent or doctor.”

In the study, parents of 448 children and adolescents with meningococcal disease either completed a questionnaire or an interview regarding the course of their child's disease an average of about 140 days after the illness; in some cases, the questionnaire or interview was supplemented by medical records. Those three early features of meningococcal disease occurred within a median of 7–12 hours after the onset of illness, compared with a median time of onset of 13–22 hours for the three classic symptoms.

The three early features of the disease in children aged 0–16 years varied in frequency and the median hour of onset: cold hands and feet (43% and 12 hours), leg pain (37% and 7 hours), and abnormal color such as pallor or mottling (19% and 10 hours).

Most (72%) of the pediatric patients had one or more of the three early features of meningococcal disease. These were first noticed at a median of 8 hours after the onset of illness, whereas patients were admitted to the hospital a median of 19 hours after the onset of illness.

Few children developed any new symptoms after 24 hours and in all age groups symptoms progressed from fever to sepsis symptoms and then to classic symptoms. Nonspecific symptoms that are common in self-limiting viral illness, such as fever, poor feeding or decreased appetite, nausea, vomiting, and irritability, developed within the first 4–6 hours of disease onset.

Dr. Thompson and his colleagues said that because these earliest symptoms are so common, it is important for parents to be able to reconsult their doctor on the same day as their initial visit if their child's condition worsens.

But these symptoms are of just as little value as leg pain, cold hands and feet, and abnormal skin color because they are so nonspecific, Dr. Reisinger said in an interview.

The investigators did not have data on the frequency of symptoms or the course of illness of children with other illnesses outside of the hospital, and so they could not make any quantitative estimate of how sensitive or specific the early symptoms could be as diagnostic markers.

“Unfortunately, [the investigators] ignore these limitations and go on to say these findings have 'important implications' for parents and clinicians,” Dr. Reisinger said.

“The greatest limitation of the study is the retrospective nature of recollection by the parents. All these families went through a very traumatic event, and we are left with no idea how accurate their recollections are,” he added.

Early symptoms, 'are not specific enough to alarm a parent or doctor.' DR. REISINGER

Recognition of the early meningococcal disease features of leg pain, cold hands and feet, and abnormal skin color may help get children to the hospital faster than classic symptoms that occur later in the illness, reported Dr. Matthew J. Thompson of the University of Oxford (England) and his associates.

The information about early symptoms came from a retrospective study that provides the first description of the time course of clinical features of meningococcal disease that occur before hospital admission, they said (Lancet 2006 Jan. 11 [Epub doi:10.1016/S0140-6736(06)67932-4]).

Meningococcal disease is typically diagnosed in children at presentation to a hospital after the onset of late-occurring classic symptoms, which include hemorrhagic rash, meningism, and impaired consciousness.

“We believe that primary care physicians are overreliant on using these three [classic] symptoms to diagnose meningococcal disease in children, and that parents may be influenced by doctors or public health campaigns to seek medical advice only on the appearance of features such as a rapidly evolving rash,” according to Dr. Thompson and his associates.

But Dr. Keith S. Reisinger, a pediatrician in private practice in Pittsburgh, contended that these early symptoms “are not specific enough to alarm a parent or doctor.”

In the study, parents of 448 children and adolescents with meningococcal disease either completed a questionnaire or an interview regarding the course of their child's disease an average of about 140 days after the illness; in some cases, the questionnaire or interview was supplemented by medical records. Those three early features of meningococcal disease occurred within a median of 7–12 hours after the onset of illness, compared with a median time of onset of 13–22 hours for the three classic symptoms.

The three early features of the disease in children aged 0–16 years varied in frequency and the median hour of onset: cold hands and feet (43% and 12 hours), leg pain (37% and 7 hours), and abnormal color such as pallor or mottling (19% and 10 hours).

Most (72%) of the pediatric patients had one or more of the three early features of meningococcal disease. These were first noticed at a median of 8 hours after the onset of illness, whereas patients were admitted to the hospital a median of 19 hours after the onset of illness.

Few children developed any new symptoms after 24 hours and in all age groups symptoms progressed from fever to sepsis symptoms and then to classic symptoms. Nonspecific symptoms that are common in self-limiting viral illness, such as fever, poor feeding or decreased appetite, nausea, vomiting, and irritability, developed within the first 4–6 hours of disease onset.

Dr. Thompson and his colleagues said that because these earliest symptoms are so common, it is important for parents to be able to reconsult their doctor on the same day as their initial visit if their child's condition worsens.

But these symptoms are of just as little value as leg pain, cold hands and feet, and abnormal skin color because they are so nonspecific, Dr. Reisinger said in an interview.

The investigators did not have data on the frequency of symptoms or the course of illness of children with other illnesses outside of the hospital, and so they could not make any quantitative estimate of how sensitive or specific the early symptoms could be as diagnostic markers.

“Unfortunately, [the investigators] ignore these limitations and go on to say these findings have 'important implications' for parents and clinicians,” Dr. Reisinger said.

“The greatest limitation of the study is the retrospective nature of recollection by the parents. All these families went through a very traumatic event, and we are left with no idea how accurate their recollections are,” he added.

Early symptoms, 'are not specific enough to alarm a parent or doctor.' DR. REISINGER

Recognition of the early meningococcal disease features of leg pain, cold hands and feet, and abnormal skin color may help get children to the hospital faster than classic symptoms that occur later in the illness, reported Dr. Matthew J. Thompson of the University of Oxford (England) and his associates.

The information about early symptoms came from a retrospective study that provides the first description of the time course of clinical features of meningococcal disease that occur before hospital admission, they said (Lancet 2006 Jan. 11 [Epub doi:10.1016/S0140-6736(06)67932-4]).

Meningococcal disease is typically diagnosed in children at presentation to a hospital after the onset of late-occurring classic symptoms, which include hemorrhagic rash, meningism, and impaired consciousness.

“We believe that primary care physicians are overreliant on using these three [classic] symptoms to diagnose meningococcal disease in children, and that parents may be influenced by doctors or public health campaigns to seek medical advice only on the appearance of features such as a rapidly evolving rash,” according to Dr. Thompson and his associates.

But Dr. Keith S. Reisinger, a pediatrician in private practice in Pittsburgh, contended that these early symptoms “are not specific enough to alarm a parent or doctor.”

In the study, parents of 448 children and adolescents with meningococcal disease either completed a questionnaire or an interview regarding the course of their child's disease an average of about 140 days after the illness; in some cases, the questionnaire or interview was supplemented by medical records. Those three early features of meningococcal disease occurred within a median of 7–12 hours after the onset of illness, compared with a median time of onset of 13–22 hours for the three classic symptoms.

The three early features of the disease in children aged 0–16 years varied in frequency and the median hour of onset: cold hands and feet (43% and 12 hours), leg pain (37% and 7 hours), and abnormal color such as pallor or mottling (19% and 10 hours).

Most (72%) of the pediatric patients had one or more of the three early features of meningococcal disease. These were first noticed at a median of 8 hours after the onset of illness, whereas patients were admitted to the hospital a median of 19 hours after the onset of illness.

Few children developed any new symptoms after 24 hours and in all age groups symptoms progressed from fever to sepsis symptoms and then to classic symptoms. Nonspecific symptoms that are common in self-limiting viral illness, such as fever, poor feeding or decreased appetite, nausea, vomiting, and irritability, developed within the first 4–6 hours of disease onset.

Dr. Thompson and his colleagues said that because these earliest symptoms are so common, it is important for parents to be able to reconsult their doctor on the same day as their initial visit if their child's condition worsens.

But these symptoms are of just as little value as leg pain, cold hands and feet, and abnormal skin color because they are so nonspecific, Dr. Reisinger said in an interview.

The investigators did not have data on the frequency of symptoms or the course of illness of children with other illnesses outside of the hospital, and so they could not make any quantitative estimate of how sensitive or specific the early symptoms could be as diagnostic markers.

“Unfortunately, [the investigators] ignore these limitations and go on to say these findings have 'important implications' for parents and clinicians,” Dr. Reisinger said.

“The greatest limitation of the study is the retrospective nature of recollection by the parents. All these families went through a very traumatic event, and we are left with no idea how accurate their recollections are,” he added.

Early symptoms, 'are not specific enough to alarm a parent or doctor.' DR. REISINGER

WASHINGTON — Most American travelers to regions endemic for hepatitis B do not receive pretravel health advice and are underimmunized, according to an anonymous survey of 618 adult travelers to such areas.

In the survey of people who traveled to countries with moderate to high rates of hepatitis B from 2000 onward, 31% of respondents visited a health practitioner to get pretravel health advice, 13% saw a travel medicine specialist, and 18% saw other health care providers, Dr. Bradley A. Connor reported during a poster session at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The strongest predictor of not seeking medical advice was travel duration of less than 20 days. Income of less than $100,000 per year also was a strong predictor of not seeking advice from a travel medicine specialist, wrote Dr. Connor, medical director of the New York Center for Travel and Tropical Medicine.

The survey respondents were international travelers identified from commercially available mailing lists; they received the survey by mail.

Respondents were significantly more likely to report having a domestic or travel-related risk factor for hepatitis B if they were age 40 years or younger, unmarried and male, or had traveled for more than 20 days. The 150 travelers who were aged 18–40 years reported significantly higher rates of domestic risk factors for hepatitis B than did the 468 older travelers (43% vs. 17%).

Compared with patients older than 40 years, younger patients also were more likely to participate in activities that were of high risk (12% vs. 7%) or potential risk (48% vs. 27%) for hepatitis B during their most recent trip.

High-risk activities were defined as an accident or illness that required invasive medical attention, a skin-perforating cosmetic procedure, or sexual intercourse with a native who was unknown to the respondent prior to travel.

Activities of potential risk for hepatitis B included sharing personal grooming items, participation in certain sporting or adventure activities, cosmetic activities with risk of skin perforation, or an accident or illness that did not require invasive care.

Hepatitis B vaccination rates on departure declined with increasing age from 33% among travelers aged 18–40 years to 19% among those aged 41–59 years and 9% among travelers aged 60 years or older.

Of the travelers who had not previously completed hepatitis B vaccination, the percentage who actually received the vaccine during their pretravel visit was 40% for those who saw a travel medicine specialist and 19% for those who visited other practitioners.

Dr. Connor reported that he is on the speaker's bureau and receives grant support from GlaxoSmithKline, which funded the study, and is on the speaker's bureau for Sanofi Pasteur; both companies manufacture hepatitis B vaccines.

WASHINGTON — Most American travelers to regions endemic for hepatitis B do not receive pretravel health advice and are underimmunized, according to an anonymous survey of 618 adult travelers to such areas.

In the survey of people who traveled to countries with moderate to high rates of hepatitis B from 2000 onward, 31% of respondents visited a health practitioner to get pretravel health advice, 13% saw a travel medicine specialist, and 18% saw other health care providers, Dr. Bradley A. Connor reported during a poster session at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The strongest predictor of not seeking medical advice was travel duration of less than 20 days. Income of less than $100,000 per year also was a strong predictor of not seeking advice from a travel medicine specialist, wrote Dr. Connor, medical director of the New York Center for Travel and Tropical Medicine.

The survey respondents were international travelers identified from commercially available mailing lists; they received the survey by mail.

Respondents were significantly more likely to report having a domestic or travel-related risk factor for hepatitis B if they were age 40 years or younger, unmarried and male, or had traveled for more than 20 days. The 150 travelers who were aged 18–40 years reported significantly higher rates of domestic risk factors for hepatitis B than did the 468 older travelers (43% vs. 17%).

Compared with patients older than 40 years, younger patients also were more likely to participate in activities that were of high risk (12% vs. 7%) or potential risk (48% vs. 27%) for hepatitis B during their most recent trip.

High-risk activities were defined as an accident or illness that required invasive medical attention, a skin-perforating cosmetic procedure, or sexual intercourse with a native who was unknown to the respondent prior to travel.

Activities of potential risk for hepatitis B included sharing personal grooming items, participation in certain sporting or adventure activities, cosmetic activities with risk of skin perforation, or an accident or illness that did not require invasive care.

Hepatitis B vaccination rates on departure declined with increasing age from 33% among travelers aged 18–40 years to 19% among those aged 41–59 years and 9% among travelers aged 60 years or older.

Of the travelers who had not previously completed hepatitis B vaccination, the percentage who actually received the vaccine during their pretravel visit was 40% for those who saw a travel medicine specialist and 19% for those who visited other practitioners.

Dr. Connor reported that he is on the speaker's bureau and receives grant support from GlaxoSmithKline, which funded the study, and is on the speaker's bureau for Sanofi Pasteur; both companies manufacture hepatitis B vaccines.

WASHINGTON — Most American travelers to regions endemic for hepatitis B do not receive pretravel health advice and are underimmunized, according to an anonymous survey of 618 adult travelers to such areas.

In the survey of people who traveled to countries with moderate to high rates of hepatitis B from 2000 onward, 31% of respondents visited a health practitioner to get pretravel health advice, 13% saw a travel medicine specialist, and 18% saw other health care providers, Dr. Bradley A. Connor reported during a poster session at the annual meeting of the American Society of Tropical Medicine and Hygiene.

The strongest predictor of not seeking medical advice was travel duration of less than 20 days. Income of less than $100,000 per year also was a strong predictor of not seeking advice from a travel medicine specialist, wrote Dr. Connor, medical director of the New York Center for Travel and Tropical Medicine.

The survey respondents were international travelers identified from commercially available mailing lists; they received the survey by mail.

Respondents were significantly more likely to report having a domestic or travel-related risk factor for hepatitis B if they were age 40 years or younger, unmarried and male, or had traveled for more than 20 days. The 150 travelers who were aged 18–40 years reported significantly higher rates of domestic risk factors for hepatitis B than did the 468 older travelers (43% vs. 17%).

Compared with patients older than 40 years, younger patients also were more likely to participate in activities that were of high risk (12% vs. 7%) or potential risk (48% vs. 27%) for hepatitis B during their most recent trip.

High-risk activities were defined as an accident or illness that required invasive medical attention, a skin-perforating cosmetic procedure, or sexual intercourse with a native who was unknown to the respondent prior to travel.

Activities of potential risk for hepatitis B included sharing personal grooming items, participation in certain sporting or adventure activities, cosmetic activities with risk of skin perforation, or an accident or illness that did not require invasive care.

Hepatitis B vaccination rates on departure declined with increasing age from 33% among travelers aged 18–40 years to 19% among those aged 41–59 years and 9% among travelers aged 60 years or older.

Of the travelers who had not previously completed hepatitis B vaccination, the percentage who actually received the vaccine during their pretravel visit was 40% for those who saw a travel medicine specialist and 19% for those who visited other practitioners.

Dr. Connor reported that he is on the speaker's bureau and receives grant support from GlaxoSmithKline, which funded the study, and is on the speaker's bureau for Sanofi Pasteur; both companies manufacture hepatitis B vaccines.

WASHINGTON — Long-term travelers to countries with high risk for malaria should use personal protective measures and chemoprophylactic regimens based on the risk factors they are likely to encounter, Patricia Schlagenhauf-Lawlor, Ph.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Long-term travelers—defined by some guidelines as those who travel for more than 6 months—include people visiting friends and relatives, expatriates, occupational travelers such as military personnel, backpackers, and missionaries. These people can use precautions that range widely in their ability to prevent infection, including personal protection measures, stand-by emergency treatment, rapid tests for malaria, seasonal chemoprophylaxis, and continuous chemoprophylaxis, said Dr. Schlagenhauf-Lawlor of the World Health Organization Collaborating Centre for Travellers' Health at the University of Zürich (Switzerland).

Personal Protection Measures

A review of randomized trials concluded that insecticide-treated nets are effective in reducing childhood mortality and morbidity due to malaria (Cochrane Database Syst. Rev. 2005;

www.thecochranelibrary.com

Clothing that has been impregnated with insecticides such as permethrin remain effective for several months. Shoes and protective (white or brightly colored) clothing also help to fend off mosquitoes, she added.

Among the mosquito repellents that are available in the United States, DEET (N,N-diethyl-m-toluamide) is still considered the best because it has been widely used and tested and is effective for more than 5 hours at concentrations of 20%. Children older than 2 months of age can use DEET, but it should be at concentrations of 10% or less.

The repellent picaridin (Bayrepel) at 19.2% concentration has been shown to cause less skin irritation while providing a level of protection similar to DEET, especially against the mosquito Anopheles gambiae. Picaridin has been approved by the Environmental Protection Agency and is safe for children older than 2 years, but studies have shown that the level and duration of protection varies between individuals, Dr. Schlagenhauf-Lawlor said.

Clinicians should avoid recommending natural oils such as citronella and eucalyptus because these oils provide only short-term protection, she said.

Mosquitoes generally prefer to bite adults rather than children, men rather than women, and large rather than small people. Some mosquitoes bite more often on the feet and ankles (A. gambiae) or face (A. atroparvus).

Travelers should learn what time of day the malaria-vector mosquitoes bite in the region they are traveling to. Bed nets may be ideal for travelers to Africa where A. gambiae is present, which prefers to feed indoors late at night. In the Amazon, repellents may work best against A. darlingi, which bites mostly in the early evening, she said.

But most long-term travelers have poor compliance with personal protection measures, Dr. Schlagenhauf-Lawlor noted. Experts consider a combination of at least four such measures to be adequate to protect against mosquito bites in high-risk areas for malaria. In a study of business travelers to high-risk areas in Africa, only 4% used four recognized methods of prevention, which include long clothes, air conditioning, repellents, insecticides, mosquito nets, and burn coils (J. Travel Med. 2003;10:219–24). Nearly all other travelers used some personal protection measures: Forty-three percent of the travelers used three measures, 25% used two, and 21% used one. Only 2% of tourists to high-risk areas in Africa used four personal protection measures (J. Travel Med. 1998;5:188–92).

Standby Emergency Treatment

The WHO defines standby emergency treatment (SBET) of malaria as the use of antimalarial drugs when malaria is suspected and prompt medical attention is unavailable within 24 hours.

For travelers in some areas, German and Swiss guidelines now recommend wider use of SBET instead of continuous prophylaxis.

“We recommend chemosuppression only when the benefit is 10 times greater than the risk of adverse effects,” Dr. Schlagenhauf-Lawlor said. “That means for most of our travelers, except for those in sub-Saharan Africa, we're recommending standby treatment and antimosquito measures.” This may be at odds with what American physicians would recommend.

Chloroquine and quinine have “very limited use” for SBET, while drugs such as mefloquine, atovaquone and proguanil (Malarone), and sulfadoxine plus pyrimethamine (Fansidar) are acceptable for SBET. Halofantrine (Halfan) is now contraindicated for SBET because of potential cardiac complications, she said.

The German and Swiss guidelines advise that chloroquine can be used for SBET in parts of Central America and the Middle East. The guidelines recommend that travelers to India use mefloquine. Travelers to the Southeast Asian countries of Myanmar, Thailand, Laos, Cambodia, and Vietnam should use Malarone for SBET because of multidrug resistant malarial strains, according to the guidelines.

The guidelines recommend continuous prophylaxis in Papua New Guinea, nearly all of sub-Saharan Africa, and in several provinces of Brazil. Continuous prophylaxis with mefloquine, doxycycline, or Malarone can be more than 90% effective if they are chosen correctly, but they cause “perceived or real” adverse events in more than 80% of patients. Many patients also fail to adhere to the dosing regimen for continuous prophylaxis and find it difficult to get the drug they need if they are traveling for more than a year, Dr. Schlagenhauf-Lawlor said.

The nonspecific symptoms of malaria make it difficult for patients to self-diagnose the disease, Dr. Schlagenhauf-Lawlor said. In a study of 1,187 Swiss travelers who carried medication for SBET, about 10% became ill with fever while traveling. Even though only nine of the travelers were out of the reach of medical attention, most of those who were ill reacted to their illness contrary to SBET instructions and delayed in seeking medical attention (Bull. World Health Organ. 1995;73:215–21).

A combination of SBET and rapid malaria tests “could be useful for certain selected long-term travelers,” she said. Studies have reported that 68%–91% of travelers were able to use the tests successfully. But the tests can generate false-positive results and have been difficult for travelers to read at low levels of parasitemia.

Seasonal Prophylaxis

In all but a few countries “it's almost impossible for an adviser to say in advance how the season will be at the destination,” Dr. Schlagenhauf-Lawlor said.

In the sub-Saharan countries of South Africa, Namibia, and Botswana, the transmission seasons are fairly stable, but can shift. In South Africa, travelers may want to use continuous prophylaxis during the high-risk season of October through May and revert to SBET during the low-risk season of June through September. But travelers should always use personal protective measures.

The high-risk season of November through June in Namibia and Botswana warrants continuous prophylaxis, while SBET and personal protective measures could be used at other times. In cases where seasonal prophylaxis may be possible, she advised that it may be best for travelers to take continuous prophylaxis for at least 6 months and then seek local advice afterward regarding the seasonal threat of malaria.

Blood-feeding Anopheles gambiae mosquitos are a leading malaria vector.

WASHINGTON — Long-term travelers to countries with high risk for malaria should use personal protective measures and chemoprophylactic regimens based on the risk factors they are likely to encounter, Patricia Schlagenhauf-Lawlor, Ph.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Long-term travelers—defined by some guidelines as those who travel for more than 6 months—include people visiting friends and relatives, expatriates, occupational travelers such as military personnel, backpackers, and missionaries. These people can use precautions that range widely in their ability to prevent infection, including personal protection measures, stand-by emergency treatment, rapid tests for malaria, seasonal chemoprophylaxis, and continuous chemoprophylaxis, said Dr. Schlagenhauf-Lawlor of the World Health Organization Collaborating Centre for Travellers' Health at the University of Zürich (Switzerland).

Personal Protection Measures

A review of randomized trials concluded that insecticide-treated nets are effective in reducing childhood mortality and morbidity due to malaria (Cochrane Database Syst. Rev. 2005;

www.thecochranelibrary.com

Clothing that has been impregnated with insecticides such as permethrin remain effective for several months. Shoes and protective (white or brightly colored) clothing also help to fend off mosquitoes, she added.

Among the mosquito repellents that are available in the United States, DEET (N,N-diethyl-m-toluamide) is still considered the best because it has been widely used and tested and is effective for more than 5 hours at concentrations of 20%. Children older than 2 months of age can use DEET, but it should be at concentrations of 10% or less.

The repellent picaridin (Bayrepel) at 19.2% concentration has been shown to cause less skin irritation while providing a level of protection similar to DEET, especially against the mosquito Anopheles gambiae. Picaridin has been approved by the Environmental Protection Agency and is safe for children older than 2 years, but studies have shown that the level and duration of protection varies between individuals, Dr. Schlagenhauf-Lawlor said.

Clinicians should avoid recommending natural oils such as citronella and eucalyptus because these oils provide only short-term protection, she said.

Mosquitoes generally prefer to bite adults rather than children, men rather than women, and large rather than small people. Some mosquitoes bite more often on the feet and ankles (A. gambiae) or face (A. atroparvus).

Travelers should learn what time of day the malaria-vector mosquitoes bite in the region they are traveling to. Bed nets may be ideal for travelers to Africa where A. gambiae is present, which prefers to feed indoors late at night. In the Amazon, repellents may work best against A. darlingi, which bites mostly in the early evening, she said.

But most long-term travelers have poor compliance with personal protection measures, Dr. Schlagenhauf-Lawlor noted. Experts consider a combination of at least four such measures to be adequate to protect against mosquito bites in high-risk areas for malaria. In a study of business travelers to high-risk areas in Africa, only 4% used four recognized methods of prevention, which include long clothes, air conditioning, repellents, insecticides, mosquito nets, and burn coils (J. Travel Med. 2003;10:219–24). Nearly all other travelers used some personal protection measures: Forty-three percent of the travelers used three measures, 25% used two, and 21% used one. Only 2% of tourists to high-risk areas in Africa used four personal protection measures (J. Travel Med. 1998;5:188–92).

Standby Emergency Treatment

The WHO defines standby emergency treatment (SBET) of malaria as the use of antimalarial drugs when malaria is suspected and prompt medical attention is unavailable within 24 hours.

For travelers in some areas, German and Swiss guidelines now recommend wider use of SBET instead of continuous prophylaxis.

“We recommend chemosuppression only when the benefit is 10 times greater than the risk of adverse effects,” Dr. Schlagenhauf-Lawlor said. “That means for most of our travelers, except for those in sub-Saharan Africa, we're recommending standby treatment and antimosquito measures.” This may be at odds with what American physicians would recommend.

Chloroquine and quinine have “very limited use” for SBET, while drugs such as mefloquine, atovaquone and proguanil (Malarone), and sulfadoxine plus pyrimethamine (Fansidar) are acceptable for SBET. Halofantrine (Halfan) is now contraindicated for SBET because of potential cardiac complications, she said.

The German and Swiss guidelines advise that chloroquine can be used for SBET in parts of Central America and the Middle East. The guidelines recommend that travelers to India use mefloquine. Travelers to the Southeast Asian countries of Myanmar, Thailand, Laos, Cambodia, and Vietnam should use Malarone for SBET because of multidrug resistant malarial strains, according to the guidelines.

The guidelines recommend continuous prophylaxis in Papua New Guinea, nearly all of sub-Saharan Africa, and in several provinces of Brazil. Continuous prophylaxis with mefloquine, doxycycline, or Malarone can be more than 90% effective if they are chosen correctly, but they cause “perceived or real” adverse events in more than 80% of patients. Many patients also fail to adhere to the dosing regimen for continuous prophylaxis and find it difficult to get the drug they need if they are traveling for more than a year, Dr. Schlagenhauf-Lawlor said.

The nonspecific symptoms of malaria make it difficult for patients to self-diagnose the disease, Dr. Schlagenhauf-Lawlor said. In a study of 1,187 Swiss travelers who carried medication for SBET, about 10% became ill with fever while traveling. Even though only nine of the travelers were out of the reach of medical attention, most of those who were ill reacted to their illness contrary to SBET instructions and delayed in seeking medical attention (Bull. World Health Organ. 1995;73:215–21).

A combination of SBET and rapid malaria tests “could be useful for certain selected long-term travelers,” she said. Studies have reported that 68%–91% of travelers were able to use the tests successfully. But the tests can generate false-positive results and have been difficult for travelers to read at low levels of parasitemia.

Seasonal Prophylaxis

In all but a few countries “it's almost impossible for an adviser to say in advance how the season will be at the destination,” Dr. Schlagenhauf-Lawlor said.

In the sub-Saharan countries of South Africa, Namibia, and Botswana, the transmission seasons are fairly stable, but can shift. In South Africa, travelers may want to use continuous prophylaxis during the high-risk season of October through May and revert to SBET during the low-risk season of June through September. But travelers should always use personal protective measures.

The high-risk season of November through June in Namibia and Botswana warrants continuous prophylaxis, while SBET and personal protective measures could be used at other times. In cases where seasonal prophylaxis may be possible, she advised that it may be best for travelers to take continuous prophylaxis for at least 6 months and then seek local advice afterward regarding the seasonal threat of malaria.

Blood-feeding Anopheles gambiae mosquitos are a leading malaria vector.

WASHINGTON — Long-term travelers to countries with high risk for malaria should use personal protective measures and chemoprophylactic regimens based on the risk factors they are likely to encounter, Patricia Schlagenhauf-Lawlor, Ph.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Long-term travelers—defined by some guidelines as those who travel for more than 6 months—include people visiting friends and relatives, expatriates, occupational travelers such as military personnel, backpackers, and missionaries. These people can use precautions that range widely in their ability to prevent infection, including personal protection measures, stand-by emergency treatment, rapid tests for malaria, seasonal chemoprophylaxis, and continuous chemoprophylaxis, said Dr. Schlagenhauf-Lawlor of the World Health Organization Collaborating Centre for Travellers' Health at the University of Zürich (Switzerland).

Personal Protection Measures

A review of randomized trials concluded that insecticide-treated nets are effective in reducing childhood mortality and morbidity due to malaria (Cochrane Database Syst. Rev. 2005;

www.thecochranelibrary.com

Clothing that has been impregnated with insecticides such as permethrin remain effective for several months. Shoes and protective (white or brightly colored) clothing also help to fend off mosquitoes, she added.

Among the mosquito repellents that are available in the United States, DEET (N,N-diethyl-m-toluamide) is still considered the best because it has been widely used and tested and is effective for more than 5 hours at concentrations of 20%. Children older than 2 months of age can use DEET, but it should be at concentrations of 10% or less.

The repellent picaridin (Bayrepel) at 19.2% concentration has been shown to cause less skin irritation while providing a level of protection similar to DEET, especially against the mosquito Anopheles gambiae. Picaridin has been approved by the Environmental Protection Agency and is safe for children older than 2 years, but studies have shown that the level and duration of protection varies between individuals, Dr. Schlagenhauf-Lawlor said.

Clinicians should avoid recommending natural oils such as citronella and eucalyptus because these oils provide only short-term protection, she said.

Mosquitoes generally prefer to bite adults rather than children, men rather than women, and large rather than small people. Some mosquitoes bite more often on the feet and ankles (A. gambiae) or face (A. atroparvus).

Travelers should learn what time of day the malaria-vector mosquitoes bite in the region they are traveling to. Bed nets may be ideal for travelers to Africa where A. gambiae is present, which prefers to feed indoors late at night. In the Amazon, repellents may work best against A. darlingi, which bites mostly in the early evening, she said.

But most long-term travelers have poor compliance with personal protection measures, Dr. Schlagenhauf-Lawlor noted. Experts consider a combination of at least four such measures to be adequate to protect against mosquito bites in high-risk areas for malaria. In a study of business travelers to high-risk areas in Africa, only 4% used four recognized methods of prevention, which include long clothes, air conditioning, repellents, insecticides, mosquito nets, and burn coils (J. Travel Med. 2003;10:219–24). Nearly all other travelers used some personal protection measures: Forty-three percent of the travelers used three measures, 25% used two, and 21% used one. Only 2% of tourists to high-risk areas in Africa used four personal protection measures (J. Travel Med. 1998;5:188–92).

Standby Emergency Treatment

The WHO defines standby emergency treatment (SBET) of malaria as the use of antimalarial drugs when malaria is suspected and prompt medical attention is unavailable within 24 hours.

For travelers in some areas, German and Swiss guidelines now recommend wider use of SBET instead of continuous prophylaxis.

“We recommend chemosuppression only when the benefit is 10 times greater than the risk of adverse effects,” Dr. Schlagenhauf-Lawlor said. “That means for most of our travelers, except for those in sub-Saharan Africa, we're recommending standby treatment and antimosquito measures.” This may be at odds with what American physicians would recommend.

Chloroquine and quinine have “very limited use” for SBET, while drugs such as mefloquine, atovaquone and proguanil (Malarone), and sulfadoxine plus pyrimethamine (Fansidar) are acceptable for SBET. Halofantrine (Halfan) is now contraindicated for SBET because of potential cardiac complications, she said.

The German and Swiss guidelines advise that chloroquine can be used for SBET in parts of Central America and the Middle East. The guidelines recommend that travelers to India use mefloquine. Travelers to the Southeast Asian countries of Myanmar, Thailand, Laos, Cambodia, and Vietnam should use Malarone for SBET because of multidrug resistant malarial strains, according to the guidelines.

The guidelines recommend continuous prophylaxis in Papua New Guinea, nearly all of sub-Saharan Africa, and in several provinces of Brazil. Continuous prophylaxis with mefloquine, doxycycline, or Malarone can be more than 90% effective if they are chosen correctly, but they cause “perceived or real” adverse events in more than 80% of patients. Many patients also fail to adhere to the dosing regimen for continuous prophylaxis and find it difficult to get the drug they need if they are traveling for more than a year, Dr. Schlagenhauf-Lawlor said.

The nonspecific symptoms of malaria make it difficult for patients to self-diagnose the disease, Dr. Schlagenhauf-Lawlor said. In a study of 1,187 Swiss travelers who carried medication for SBET, about 10% became ill with fever while traveling. Even though only nine of the travelers were out of the reach of medical attention, most of those who were ill reacted to their illness contrary to SBET instructions and delayed in seeking medical attention (Bull. World Health Organ. 1995;73:215–21).

A combination of SBET and rapid malaria tests “could be useful for certain selected long-term travelers,” she said. Studies have reported that 68%–91% of travelers were able to use the tests successfully. But the tests can generate false-positive results and have been difficult for travelers to read at low levels of parasitemia.

Seasonal Prophylaxis

In all but a few countries “it's almost impossible for an adviser to say in advance how the season will be at the destination,” Dr. Schlagenhauf-Lawlor said.

In the sub-Saharan countries of South Africa, Namibia, and Botswana, the transmission seasons are fairly stable, but can shift. In South Africa, travelers may want to use continuous prophylaxis during the high-risk season of October through May and revert to SBET during the low-risk season of June through September. But travelers should always use personal protective measures.

The high-risk season of November through June in Namibia and Botswana warrants continuous prophylaxis, while SBET and personal protective measures could be used at other times. In cases where seasonal prophylaxis may be possible, she advised that it may be best for travelers to take continuous prophylaxis for at least 6 months and then seek local advice afterward regarding the seasonal threat of malaria.

Blood-feeding Anopheles gambiae mosquitos are a leading malaria vector.

BETHESDA, MD. – Treatment for substance use disorders continues to be out of reach for many people who need it at a time when funding for treatment and health plan coverage of substance abuse remains stagnant, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University in Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%).

Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). (Some respondents reported more than one source of payment.)

People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting–1.8% of all health care expenditures–came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003.

The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%. The percentage of plans in which behavioral health services were contracted out but remained as a part of general health coverage stayed steady at 14%.

Across the country, 95%–100% of all health plan products covered outpatient, inpatient, and residential detoxification, outpatient rehabilitation, intensive outpatient services, and intensive hospital treatment.

Coverage extended to methadone maintenance in 65% of health plans and to residential rehabilitation in 84%.

Prescription benefits for medications used in substance abuse treatment are part of the main health plan, not the behavioral health plan, “so it's important to look at what your prescription drug benefit is and where do the substance abuse medications fall in your health plan,” Dr. Horgan advised.

In 2003, about 90% of health plans covered alcohol abuse medications, but in some instances these drugs were given the highest copayment rates, such as with ReVia (naltrexone, 41%), or Antabuse (disulfiram, 27%).

The opioid abuse drug Suboxone (combination of buprenorphine and naloxone) was excluded from coverage by 33% of health plans; 53% of the plans that covered Suboxone placed it on the highest copayment rate.

Health plans that used high cost-sharing schemes for outpatient visits increased from 24% in 1999 to 41% in 2003. A similar, but sharper, increase occurred in general medical outpatient visits, from 4% of plans in 1999 to 37% in 2003. High cost-sharing was arbitrarily defined as coinsurance greater than 20% or a copayment greater than $20, Dr. Horgan said.

BETHESDA, MD. – Treatment for substance use disorders continues to be out of reach for many people who need it at a time when funding for treatment and health plan coverage of substance abuse remains stagnant, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University in Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%).

Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). (Some respondents reported more than one source of payment.)

People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting–1.8% of all health care expenditures–came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003.

The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%. The percentage of plans in which behavioral health services were contracted out but remained as a part of general health coverage stayed steady at 14%.

Across the country, 95%–100% of all health plan products covered outpatient, inpatient, and residential detoxification, outpatient rehabilitation, intensive outpatient services, and intensive hospital treatment.

Coverage extended to methadone maintenance in 65% of health plans and to residential rehabilitation in 84%.

Prescription benefits for medications used in substance abuse treatment are part of the main health plan, not the behavioral health plan, “so it's important to look at what your prescription drug benefit is and where do the substance abuse medications fall in your health plan,” Dr. Horgan advised.

In 2003, about 90% of health plans covered alcohol abuse medications, but in some instances these drugs were given the highest copayment rates, such as with ReVia (naltrexone, 41%), or Antabuse (disulfiram, 27%).

The opioid abuse drug Suboxone (combination of buprenorphine and naloxone) was excluded from coverage by 33% of health plans; 53% of the plans that covered Suboxone placed it on the highest copayment rate.

Health plans that used high cost-sharing schemes for outpatient visits increased from 24% in 1999 to 41% in 2003. A similar, but sharper, increase occurred in general medical outpatient visits, from 4% of plans in 1999 to 37% in 2003. High cost-sharing was arbitrarily defined as coinsurance greater than 20% or a copayment greater than $20, Dr. Horgan said.

BETHESDA, MD. – Treatment for substance use disorders continues to be out of reach for many people who need it at a time when funding for treatment and health plan coverage of substance abuse remains stagnant, Constance M. Horgan, Sc.D., said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Horgan used data obtained from the 2003 and 2004 National Survey on Drug Use and Health (NSDUH, formerly called the National Household Survey on Drug Abuse) and her own two surveys of behavioral health service coverage in managed care health plans to chart recent trends in substance abuse treatment.

“Not many people are making the link to specialty treatment” of substance use disorders, said Dr. Horgan, director of the Center for Behavioral Health at the Schneider Institute for Health Policy at Brandeis University in Waltham, Mass.

Only 9% of the estimated 22.5 million people 12 years of age or older with a drug or alcohol problem needing treatment actually received specialty treatment in an outpatient or inpatient rehabilitation setting, a mental health center, or as a hospital inpatient, averaged data from the 2003 and 2004 NSDUH show.

Of the people who were thought to need treatment but did not receive specialty treatment, 94% felt that they did not need treatment, according to the 2004 NSDUH. Among those who thought they needed treatment, 2% made an effort to receive it, and 4% did not.

Of the 6% who felt they needed treatment, most reported that they had not received specialty treatment because they were not ready to stop using drugs (40%), had cost and insurance barriers (35%), were afraid of stigma (22%), felt they could handle the problem themselves through friends or other support (14%), did not know where to go for treatment (12%), or had barriers to accessing treatment (13%), such as transportation, no openings, waiting lists, or unavailable services.

The people who thought that they needed treatment but had cost and insurance barriers fell into groups of those who had no health coverage and could not afford the cost of insurance (28%), and those who had health insurance that did not cover the cost of treatment (7%).

Among those who had no health insurance and could not afford the cost of the treatment, 32% still made an effort to get treatment. “This says something about access issues and the need for public payment,” Dr. Horgan said.

In the past year, individuals paid for their last substance use treatment at a specialty facility most often with their own money (43%), with funds from their family (21%), or with private insurance (38%).

Some patients also reported paying for their last treatment with Medicaid (29%), Medicare (23%), or another public sector payer (22%). (Some respondents reported more than one source of payment.)

People typically think that most of these patients use public sector payers and do not have much out-of-pocket expense, Dr. Horgan said at the conference sponsored by the Brown Medical School.

In 2001, most of the $18.3 billion spent on the direct treatment costs of substance abuse in any medical setting–1.8% of all health care expenditures–came from public sector payers: Medicaid (19%), Medicare (5%), and other state and local (38%) or federal (14%) means. The bulk of expenditures for substance abuse were distributed to inpatient (30%) and residential (24%) settings of care. Only 40% of expenditures went to outpatient services, although most patients receive care in that setting, she said. Insurance administration collected 6% of the expenditures.

In a survey of U.S. managed care health plans that Dr. Horgan and her colleagues conducted in 1999 and 2003, the percentage of plans that contracted behavioral health services out to specialty vendors grew from 58% in 1999 to 71% in 2003.

The percentage of plans in which network providers were internal to the plan declined in the same period from 28% to 15%. The percentage of plans in which behavioral health services were contracted out but remained as a part of general health coverage stayed steady at 14%.

Across the country, 95%–100% of all health plan products covered outpatient, inpatient, and residential detoxification, outpatient rehabilitation, intensive outpatient services, and intensive hospital treatment.

Coverage extended to methadone maintenance in 65% of health plans and to residential rehabilitation in 84%.

Prescription benefits for medications used in substance abuse treatment are part of the main health plan, not the behavioral health plan, “so it's important to look at what your prescription drug benefit is and where do the substance abuse medications fall in your health plan,” Dr. Horgan advised.

In 2003, about 90% of health plans covered alcohol abuse medications, but in some instances these drugs were given the highest copayment rates, such as with ReVia (naltrexone, 41%), or Antabuse (disulfiram, 27%).

The opioid abuse drug Suboxone (combination of buprenorphine and naloxone) was excluded from coverage by 33% of health plans; 53% of the plans that covered Suboxone placed it on the highest copayment rate.

Health plans that used high cost-sharing schemes for outpatient visits increased from 24% in 1999 to 41% in 2003. A similar, but sharper, increase occurred in general medical outpatient visits, from 4% of plans in 1999 to 37% in 2003. High cost-sharing was arbitrarily defined as coinsurance greater than 20% or a copayment greater than $20, Dr. Horgan said.

BETHESDA, MD. – Very little published evidence exists to back treatments for adolescents with opioid abuse or dependence.

In addition, those adolescents appear to have characteristics that differ from those abusing or dependent on marijuana or alcohol, Dr. Geetha Subramaniam reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Most of the studies on treatments for adolescent opioid users were published in the 1960s and 1970s, and included no randomized trials or control groups (J. Subst. Abuse Treat. 2002;23:231–7), said Dr. Subramaniam of Johns Hopkins University, Baltimore.

Methadone maintenance treatment is known to work for adolescents if it is given for a long enough period of time and in high enough doses. But it is tough for patients under age 18 to qualify for methadone maintenance treatment and to find a provider who is willing to treat them.

Even for adult patients, many physicians are uncomfortable with prescribing methadone because of concerns about addiction.

For adolescents, drug-free treatment in therapeutic communities for up to 6 months is known to be effective. But in many cases, it is not cost effective to place a patient in residential treatment for 6 months, Dr. Subramaniam pointed out.

In a recently published randomized, controlled trial of 36 adolescent opioid users who participated in a 28-day course of detoxification, a significantly greater percentage of patients who received 6–8 mg of buprenorphine remained in treatment (72%) and had a higher percentage of opioid-negative urine samples (64%) than did patients who received 0.1–0.3 mg of clonidine (39% and 32%, respectively) (Arch. Gen. Psychiatry 2005;62:1157–64).

Another trial is enrolling heroin-addicted patients 14–21 years old to compare a 12-week course of buprenorphine and naloxone (the combination is marketed as Suboxone) with a standard 2-week course of Suboxone.

Adult opioid users have had success with psychosocial treatments in outpatient (cognitive-behavioral therapy, contingency management, or self-help groups) or residential settings (therapeutic community). For those patients, methadone maintenance treatment has been shown to reduce opiate use and mortality. But researchers have not conducted any treatment trials comparing psychosocial treatments for opioid users who are adolescents.

The few published U.S. studies of comorbidities in adolescents with opioid use disorders are limited by their focus on heroin or opioid users rather than on those who had progressed to abuse and dependence, Dr. Subramaniam said.

Those studies found that most users were male and white, came from single-family homes, and had psychiatric and legal problems.

The reports showed that most of the adolescents used other drugs, and about half injected drugs.

At Johns Hopkins, Dr. Subramaniam is conducting a study examining the differences between adolescents diagnosed with an opioid use disorder and those diagnosed with a marijuana and/or alcohol use disorder. The diagnosis of a “use disorder” connotes drug abuse or dependence.

Dr. Subramaniam presented results on 40 patients in each group; about 100 patients are expected to be recruited for each arm of the study. The patients are matched for age, gender, inpatient and outpatient status, and cocaine use in the past 30 days.

Whites made up a significantly higher percentage of opioid users (95%) than marijuana/alcohol users (48%). Dropout rates from school were significantly higher in opioid users (70%) than marijuana/alcohol users (33%). The average age of the patients in each group was about 17 years.

Most (65%) of the adolescents with opioid use disorder named heroin, oxycodone, or other opiates as their drug of first choice, but 19% called cocaine their first choice. Most (73%) patients in the comparison group reported marijuana as their drug of first choice, followed by cocaine and then alcohol.

Patients in both groups first began regularly using marijuana (about 14 years) and alcohol (13.2–13.5 years) at a similar average age. But patients with opioid use disorders began regularly using opioids and cocaine at a significantly younger age (15.2 years and 15.7 years, respectively) than patients in the comparison group (16.8 years for both).

“Somehow [patients with opioid use disorder are] gravitating into harder drugs much earlier” than the comparison group, Dr. Subramaniam said. “What facilitates this kind of trajectory, I don't know, but that is an important point for us to think about.”

In the past year, patients with an opioid use disorder had a concomitant cocaine or sedative use disorder in a significantly higher percentage of cases than those with marijuana/alcohol use disorders. Both groups had high, but not significantly different, prevalences of psychiatric diagnoses in the past year.

Opioid users had engaged in behaviors in the past 30 days that put them at risk for HIV at significantly higher rates than patients in the comparison group, including injection drug use (43% vs. 3%) and never using condoms (38% vs. 18%).

Opioid users reported driving under the influence of any drug on an average of 97 occasions during the previous 90 days, which was significantly more than the average of 34 occasions reported by patients in the comparison group.

Opioid users may be using drugs to treat withdrawal symptoms to make them feel better before they go to work, Dr. Subramaniam said at the conference, which was also sponsored by Brown Medical School.

Trials comparing psychosocial treatments for adolescent opioid users have not been conducted. DR. SUBRAMANIAM

BETHESDA, MD. – Very little published evidence exists to back treatments for adolescents with opioid abuse or dependence.

In addition, those adolescents appear to have characteristics that differ from those abusing or dependent on marijuana or alcohol, Dr. Geetha Subramaniam reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Most of the studies on treatments for adolescent opioid users were published in the 1960s and 1970s, and included no randomized trials or control groups (J. Subst. Abuse Treat. 2002;23:231–7), said Dr. Subramaniam of Johns Hopkins University, Baltimore.

Methadone maintenance treatment is known to work for adolescents if it is given for a long enough period of time and in high enough doses. But it is tough for patients under age 18 to qualify for methadone maintenance treatment and to find a provider who is willing to treat them.

Even for adult patients, many physicians are uncomfortable with prescribing methadone because of concerns about addiction.

For adolescents, drug-free treatment in therapeutic communities for up to 6 months is known to be effective. But in many cases, it is not cost effective to place a patient in residential treatment for 6 months, Dr. Subramaniam pointed out.

In a recently published randomized, controlled trial of 36 adolescent opioid users who participated in a 28-day course of detoxification, a significantly greater percentage of patients who received 6–8 mg of buprenorphine remained in treatment (72%) and had a higher percentage of opioid-negative urine samples (64%) than did patients who received 0.1–0.3 mg of clonidine (39% and 32%, respectively) (Arch. Gen. Psychiatry 2005;62:1157–64).

Another trial is enrolling heroin-addicted patients 14–21 years old to compare a 12-week course of buprenorphine and naloxone (the combination is marketed as Suboxone) with a standard 2-week course of Suboxone.

Adult opioid users have had success with psychosocial treatments in outpatient (cognitive-behavioral therapy, contingency management, or self-help groups) or residential settings (therapeutic community). For those patients, methadone maintenance treatment has been shown to reduce opiate use and mortality. But researchers have not conducted any treatment trials comparing psychosocial treatments for opioid users who are adolescents.

The few published U.S. studies of comorbidities in adolescents with opioid use disorders are limited by their focus on heroin or opioid users rather than on those who had progressed to abuse and dependence, Dr. Subramaniam said.

Those studies found that most users were male and white, came from single-family homes, and had psychiatric and legal problems.

The reports showed that most of the adolescents used other drugs, and about half injected drugs.

At Johns Hopkins, Dr. Subramaniam is conducting a study examining the differences between adolescents diagnosed with an opioid use disorder and those diagnosed with a marijuana and/or alcohol use disorder. The diagnosis of a “use disorder” connotes drug abuse or dependence.

Dr. Subramaniam presented results on 40 patients in each group; about 100 patients are expected to be recruited for each arm of the study. The patients are matched for age, gender, inpatient and outpatient status, and cocaine use in the past 30 days.

Whites made up a significantly higher percentage of opioid users (95%) than marijuana/alcohol users (48%). Dropout rates from school were significantly higher in opioid users (70%) than marijuana/alcohol users (33%). The average age of the patients in each group was about 17 years.

Most (65%) of the adolescents with opioid use disorder named heroin, oxycodone, or other opiates as their drug of first choice, but 19% called cocaine their first choice. Most (73%) patients in the comparison group reported marijuana as their drug of first choice, followed by cocaine and then alcohol.

Patients in both groups first began regularly using marijuana (about 14 years) and alcohol (13.2–13.5 years) at a similar average age. But patients with opioid use disorders began regularly using opioids and cocaine at a significantly younger age (15.2 years and 15.7 years, respectively) than patients in the comparison group (16.8 years for both).

“Somehow [patients with opioid use disorder are] gravitating into harder drugs much earlier” than the comparison group, Dr. Subramaniam said. “What facilitates this kind of trajectory, I don't know, but that is an important point for us to think about.”

In the past year, patients with an opioid use disorder had a concomitant cocaine or sedative use disorder in a significantly higher percentage of cases than those with marijuana/alcohol use disorders. Both groups had high, but not significantly different, prevalences of psychiatric diagnoses in the past year.

Opioid users had engaged in behaviors in the past 30 days that put them at risk for HIV at significantly higher rates than patients in the comparison group, including injection drug use (43% vs. 3%) and never using condoms (38% vs. 18%).

Opioid users reported driving under the influence of any drug on an average of 97 occasions during the previous 90 days, which was significantly more than the average of 34 occasions reported by patients in the comparison group.

Opioid users may be using drugs to treat withdrawal symptoms to make them feel better before they go to work, Dr. Subramaniam said at the conference, which was also sponsored by Brown Medical School.

Trials comparing psychosocial treatments for adolescent opioid users have not been conducted. DR. SUBRAMANIAM

BETHESDA, MD. – Very little published evidence exists to back treatments for adolescents with opioid abuse or dependence.

In addition, those adolescents appear to have characteristics that differ from those abusing or dependent on marijuana or alcohol, Dr. Geetha Subramaniam reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Most of the studies on treatments for adolescent opioid users were published in the 1960s and 1970s, and included no randomized trials or control groups (J. Subst. Abuse Treat. 2002;23:231–7), said Dr. Subramaniam of Johns Hopkins University, Baltimore.

Methadone maintenance treatment is known to work for adolescents if it is given for a long enough period of time and in high enough doses. But it is tough for patients under age 18 to qualify for methadone maintenance treatment and to find a provider who is willing to treat them.

Even for adult patients, many physicians are uncomfortable with prescribing methadone because of concerns about addiction.

For adolescents, drug-free treatment in therapeutic communities for up to 6 months is known to be effective. But in many cases, it is not cost effective to place a patient in residential treatment for 6 months, Dr. Subramaniam pointed out.

In a recently published randomized, controlled trial of 36 adolescent opioid users who participated in a 28-day course of detoxification, a significantly greater percentage of patients who received 6–8 mg of buprenorphine remained in treatment (72%) and had a higher percentage of opioid-negative urine samples (64%) than did patients who received 0.1–0.3 mg of clonidine (39% and 32%, respectively) (Arch. Gen. Psychiatry 2005;62:1157–64).

Another trial is enrolling heroin-addicted patients 14–21 years old to compare a 12-week course of buprenorphine and naloxone (the combination is marketed as Suboxone) with a standard 2-week course of Suboxone.

Adult opioid users have had success with psychosocial treatments in outpatient (cognitive-behavioral therapy, contingency management, or self-help groups) or residential settings (therapeutic community). For those patients, methadone maintenance treatment has been shown to reduce opiate use and mortality. But researchers have not conducted any treatment trials comparing psychosocial treatments for opioid users who are adolescents.

The few published U.S. studies of comorbidities in adolescents with opioid use disorders are limited by their focus on heroin or opioid users rather than on those who had progressed to abuse and dependence, Dr. Subramaniam said.

Those studies found that most users were male and white, came from single-family homes, and had psychiatric and legal problems.

The reports showed that most of the adolescents used other drugs, and about half injected drugs.

At Johns Hopkins, Dr. Subramaniam is conducting a study examining the differences between adolescents diagnosed with an opioid use disorder and those diagnosed with a marijuana and/or alcohol use disorder. The diagnosis of a “use disorder” connotes drug abuse or dependence.

Dr. Subramaniam presented results on 40 patients in each group; about 100 patients are expected to be recruited for each arm of the study. The patients are matched for age, gender, inpatient and outpatient status, and cocaine use in the past 30 days.

Whites made up a significantly higher percentage of opioid users (95%) than marijuana/alcohol users (48%). Dropout rates from school were significantly higher in opioid users (70%) than marijuana/alcohol users (33%). The average age of the patients in each group was about 17 years.

Most (65%) of the adolescents with opioid use disorder named heroin, oxycodone, or other opiates as their drug of first choice, but 19% called cocaine their first choice. Most (73%) patients in the comparison group reported marijuana as their drug of first choice, followed by cocaine and then alcohol.

Patients in both groups first began regularly using marijuana (about 14 years) and alcohol (13.2–13.5 years) at a similar average age. But patients with opioid use disorders began regularly using opioids and cocaine at a significantly younger age (15.2 years and 15.7 years, respectively) than patients in the comparison group (16.8 years for both).

“Somehow [patients with opioid use disorder are] gravitating into harder drugs much earlier” than the comparison group, Dr. Subramaniam said. “What facilitates this kind of trajectory, I don't know, but that is an important point for us to think about.”

In the past year, patients with an opioid use disorder had a concomitant cocaine or sedative use disorder in a significantly higher percentage of cases than those with marijuana/alcohol use disorders. Both groups had high, but not significantly different, prevalences of psychiatric diagnoses in the past year.

Opioid users had engaged in behaviors in the past 30 days that put them at risk for HIV at significantly higher rates than patients in the comparison group, including injection drug use (43% vs. 3%) and never using condoms (38% vs. 18%).

Opioid users reported driving under the influence of any drug on an average of 97 occasions during the previous 90 days, which was significantly more than the average of 34 occasions reported by patients in the comparison group.

Opioid users may be using drugs to treat withdrawal symptoms to make them feel better before they go to work, Dr. Subramaniam said at the conference, which was also sponsored by Brown Medical School.

Trials comparing psychosocial treatments for adolescent opioid users have not been conducted. DR. SUBRAMANIAM

NEW YORK – The body of data for using newer pharmacotherapeutic agents to treat autistic symptoms is struggling to keep up with the use of such drugs in practice, Lawrence Scahill, Ph.D., said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“An evidence-based discussion of autism is relatively brief, because we don't have a lot of evidence, unfortunately,” said Dr. Scahill, director of the research unit on pediatric psychopharmacology at the Yale Child Study Center, New Haven, Conn.

“We don't have great medications for the core symptoms of autism,” such as delay or disinterest in social interaction, repetitive behavior and restricted interests, and impaired communication. But some medications have proven to be useful in treating target symptoms, such as hyperactivity, tantrums, aggression, self-injury, and anxiety, he added.

In a survey of medication patterns in patients with autism or pervasive developmental disorder (PDD) in North Carolina, the use of any medication to treat the conditions rose from 31% in 1992–1993 to 45% in 2001, even though data do not exist to support the use of many medications, Dr. Scahill noted (J. Child Adolesc. Psychopharmacol. 2005;15:116–26).

The use of several classes of drugs rose noticeably during that period, including antipsychotics (from 12% to 17%), antidepressants (from 6% to 21%), and stimulants (from 7% to 14%). For antipsychotics and antidepressants, these changes reflect switches to atypicals and SSRIs, said Dr. Scahill, who disclosed that he serves as a consultant for Janssen Pharmaceutica N.V., which manufactures risperidone (Risperdal), and Pfizer Inc., which is the manufacturer of fluoxetine.

SSRIs for Repetitive Behavior, Anxiety

SSRIs such as fluoxetine have been used in PDD to treat repetitive behavior, anxiety, and aggression, as well as to improve socialization, Dr. Scahill said.

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo in a randomized, double-blind, crossover study of 39 children and adolescents with autistic spectrum disorders.

In the first phase of the trial, patients who received fluoxetine improved their scores on a clinician-rated instrument focused on repetitive behavior (the Children's Yale-Brown Obsessive Compulsive Scale-PDD) by 10% (12.8 to 11.6), compared with placebo patients who improved by 4% (from 13.4 to 12.9). The second phase of the study, in which the patients switched treatments, yielded similar results.

Adverse events occurred at a rate similar to that of placebo. The patients received an average dose of fluoxetine of 10 mg/day, beginning with 2.5 mg/day for the first week.

By increasing the dose slowly, the investigators avoided SSRI-induced activation, which may include insomnia and increased motor activity, talkativeness, impulsive behavior, or aggression, Dr. Scahill said.

“In terms of benefit, if you're aiming [SSRIs] at repetitive behavior, I don't say 'Don't do it,' but don't expect big effects,” he said.

Aggression, Tantrums, Self-Injury

Risperidone is the atypical antipsychotic that has been studied most extensively in PDD. Open and controlled trials with risperidone have involved 223 patients with PDD. The Food and Drug Administration previously declared risperidone as nonapprovable for the treatment of autism in children, but it is now being submitted for approval for the treatment of tantrums, aggression, and self-injury, Dr. Scahill said.

In an 8-week, randomized, double-blind trial, risperidone significantly reduced aggressive behavior, tantrums, and self-injurious behavior by 57% in 49 children, compared with 14% in 52 children on placebo, according to the parent-rated irritability subscale of the Aberrant Behavior Checklist. Clinician ratings yielded similar results. The patients averaged 1.8 mg per day (N. Engl. J. Med. 2002;347:314–21).

During a 4-month open-label extension of the study for 63 responders to risperidone, irritability scores did not worsen, and patients did not require more risperidone to maintain their response (Am. J. Psychiatry 2005;162:1361–9). These responders gained an average of 5.6 kg during a total of 6 months of treatment with risperidone (Am. J. Psychiatry 2004;161:1125–7).

In a 2-month, randomized, double-blind discontinuation of risperidone, patients who continued to receive risperidone had a significantly lower rate of relapse (2 of 16) than did patients who gradually replaced risperidone with placebo (10 of 16).

ADHD Symptoms

Even though “we know that hyperactivity is a very common problem” in children and adolescents with PDD, “the evidence to support the use of methylphenidate in this population is frightfully little,” Dr. Scahill said.

Until recently, methylphenidate had been studied in only two trials of 10 children with PDD and ADHD. On the Conners Hyperactivity Index, teachers reported 11% improvement at a dose of 10–20 mg twice daily (J. Autism Dev. Disord. 1995;25:283–94), 32% improvement at 0.3 mg/kg per dose, and 47% improvement at 0.6 mg/kg (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:805–12).

In a more rigorous study of 66 children with PDD and hyperactivity conducted by Dr. Scahill and his colleagues, methylphenidate improved hyperactivity significantly but to a lesser degree than it would in typically developing children with ADHD, according to teacher and parent ratings (Arch. Gen. Psychiatry 2005;62:1266–74). Children in the randomized, double-blind, crossover trial tolerated three dose levels of methylphenidate during a 7-day test dose period and then received placebo for 1 week, followed by 3 weeks of the three methylphenidate doses in random order.

Thirty-four patients who responded to treatment based on a less conservative definition of response later received 8 weeks of open-label methylphenidate at an individually determined best dose. Adverse events such as decreased appetite and increased repetitive behavior and stereotypies occurred mainly with the highest dose, even though it was “not really that high” (0.5–0.6 mg/kg per dose), Dr. Scahill said. Few adverse events occurred in the 38% (25 of 66) of patients who responded to either the low (0.125–0.18 mg/kg per dose) or the medium dose (0.25–0.35 mg/kg per dose).

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo. DR. SCAHILL

NEW YORK – The body of data for using newer pharmacotherapeutic agents to treat autistic symptoms is struggling to keep up with the use of such drugs in practice, Lawrence Scahill, Ph.D., said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“An evidence-based discussion of autism is relatively brief, because we don't have a lot of evidence, unfortunately,” said Dr. Scahill, director of the research unit on pediatric psychopharmacology at the Yale Child Study Center, New Haven, Conn.

“We don't have great medications for the core symptoms of autism,” such as delay or disinterest in social interaction, repetitive behavior and restricted interests, and impaired communication. But some medications have proven to be useful in treating target symptoms, such as hyperactivity, tantrums, aggression, self-injury, and anxiety, he added.

In a survey of medication patterns in patients with autism or pervasive developmental disorder (PDD) in North Carolina, the use of any medication to treat the conditions rose from 31% in 1992–1993 to 45% in 2001, even though data do not exist to support the use of many medications, Dr. Scahill noted (J. Child Adolesc. Psychopharmacol. 2005;15:116–26).

The use of several classes of drugs rose noticeably during that period, including antipsychotics (from 12% to 17%), antidepressants (from 6% to 21%), and stimulants (from 7% to 14%). For antipsychotics and antidepressants, these changes reflect switches to atypicals and SSRIs, said Dr. Scahill, who disclosed that he serves as a consultant for Janssen Pharmaceutica N.V., which manufactures risperidone (Risperdal), and Pfizer Inc., which is the manufacturer of fluoxetine.

SSRIs for Repetitive Behavior, Anxiety

SSRIs such as fluoxetine have been used in PDD to treat repetitive behavior, anxiety, and aggression, as well as to improve socialization, Dr. Scahill said.

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo in a randomized, double-blind, crossover study of 39 children and adolescents with autistic spectrum disorders.

In the first phase of the trial, patients who received fluoxetine improved their scores on a clinician-rated instrument focused on repetitive behavior (the Children's Yale-Brown Obsessive Compulsive Scale-PDD) by 10% (12.8 to 11.6), compared with placebo patients who improved by 4% (from 13.4 to 12.9). The second phase of the study, in which the patients switched treatments, yielded similar results.

Adverse events occurred at a rate similar to that of placebo. The patients received an average dose of fluoxetine of 10 mg/day, beginning with 2.5 mg/day for the first week.

By increasing the dose slowly, the investigators avoided SSRI-induced activation, which may include insomnia and increased motor activity, talkativeness, impulsive behavior, or aggression, Dr. Scahill said.

“In terms of benefit, if you're aiming [SSRIs] at repetitive behavior, I don't say 'Don't do it,' but don't expect big effects,” he said.

Aggression, Tantrums, Self-Injury

Risperidone is the atypical antipsychotic that has been studied most extensively in PDD. Open and controlled trials with risperidone have involved 223 patients with PDD. The Food and Drug Administration previously declared risperidone as nonapprovable for the treatment of autism in children, but it is now being submitted for approval for the treatment of tantrums, aggression, and self-injury, Dr. Scahill said.

In an 8-week, randomized, double-blind trial, risperidone significantly reduced aggressive behavior, tantrums, and self-injurious behavior by 57% in 49 children, compared with 14% in 52 children on placebo, according to the parent-rated irritability subscale of the Aberrant Behavior Checklist. Clinician ratings yielded similar results. The patients averaged 1.8 mg per day (N. Engl. J. Med. 2002;347:314–21).

During a 4-month open-label extension of the study for 63 responders to risperidone, irritability scores did not worsen, and patients did not require more risperidone to maintain their response (Am. J. Psychiatry 2005;162:1361–9). These responders gained an average of 5.6 kg during a total of 6 months of treatment with risperidone (Am. J. Psychiatry 2004;161:1125–7).

In a 2-month, randomized, double-blind discontinuation of risperidone, patients who continued to receive risperidone had a significantly lower rate of relapse (2 of 16) than did patients who gradually replaced risperidone with placebo (10 of 16).

ADHD Symptoms

Even though “we know that hyperactivity is a very common problem” in children and adolescents with PDD, “the evidence to support the use of methylphenidate in this population is frightfully little,” Dr. Scahill said.

Until recently, methylphenidate had been studied in only two trials of 10 children with PDD and ADHD. On the Conners Hyperactivity Index, teachers reported 11% improvement at a dose of 10–20 mg twice daily (J. Autism Dev. Disord. 1995;25:283–94), 32% improvement at 0.3 mg/kg per dose, and 47% improvement at 0.6 mg/kg (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:805–12).

In a more rigorous study of 66 children with PDD and hyperactivity conducted by Dr. Scahill and his colleagues, methylphenidate improved hyperactivity significantly but to a lesser degree than it would in typically developing children with ADHD, according to teacher and parent ratings (Arch. Gen. Psychiatry 2005;62:1266–74). Children in the randomized, double-blind, crossover trial tolerated three dose levels of methylphenidate during a 7-day test dose period and then received placebo for 1 week, followed by 3 weeks of the three methylphenidate doses in random order.

Thirty-four patients who responded to treatment based on a less conservative definition of response later received 8 weeks of open-label methylphenidate at an individually determined best dose. Adverse events such as decreased appetite and increased repetitive behavior and stereotypies occurred mainly with the highest dose, even though it was “not really that high” (0.5–0.6 mg/kg per dose), Dr. Scahill said. Few adverse events occurred in the 38% (25 of 66) of patients who responded to either the low (0.125–0.18 mg/kg per dose) or the medium dose (0.25–0.35 mg/kg per dose).

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo. DR. SCAHILL

NEW YORK – The body of data for using newer pharmacotherapeutic agents to treat autistic symptoms is struggling to keep up with the use of such drugs in practice, Lawrence Scahill, Ph.D., said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“An evidence-based discussion of autism is relatively brief, because we don't have a lot of evidence, unfortunately,” said Dr. Scahill, director of the research unit on pediatric psychopharmacology at the Yale Child Study Center, New Haven, Conn.

“We don't have great medications for the core symptoms of autism,” such as delay or disinterest in social interaction, repetitive behavior and restricted interests, and impaired communication. But some medications have proven to be useful in treating target symptoms, such as hyperactivity, tantrums, aggression, self-injury, and anxiety, he added.

In a survey of medication patterns in patients with autism or pervasive developmental disorder (PDD) in North Carolina, the use of any medication to treat the conditions rose from 31% in 1992–1993 to 45% in 2001, even though data do not exist to support the use of many medications, Dr. Scahill noted (J. Child Adolesc. Psychopharmacol. 2005;15:116–26).

The use of several classes of drugs rose noticeably during that period, including antipsychotics (from 12% to 17%), antidepressants (from 6% to 21%), and stimulants (from 7% to 14%). For antipsychotics and antidepressants, these changes reflect switches to atypicals and SSRIs, said Dr. Scahill, who disclosed that he serves as a consultant for Janssen Pharmaceutica N.V., which manufactures risperidone (Risperdal), and Pfizer Inc., which is the manufacturer of fluoxetine.

SSRIs for Repetitive Behavior, Anxiety

SSRIs such as fluoxetine have been used in PDD to treat repetitive behavior, anxiety, and aggression, as well as to improve socialization, Dr. Scahill said.

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo in a randomized, double-blind, crossover study of 39 children and adolescents with autistic spectrum disorders.

In the first phase of the trial, patients who received fluoxetine improved their scores on a clinician-rated instrument focused on repetitive behavior (the Children's Yale-Brown Obsessive Compulsive Scale-PDD) by 10% (12.8 to 11.6), compared with placebo patients who improved by 4% (from 13.4 to 12.9). The second phase of the study, in which the patients switched treatments, yielded similar results.

Adverse events occurred at a rate similar to that of placebo. The patients received an average dose of fluoxetine of 10 mg/day, beginning with 2.5 mg/day for the first week.

By increasing the dose slowly, the investigators avoided SSRI-induced activation, which may include insomnia and increased motor activity, talkativeness, impulsive behavior, or aggression, Dr. Scahill said.

“In terms of benefit, if you're aiming [SSRIs] at repetitive behavior, I don't say 'Don't do it,' but don't expect big effects,” he said.

Aggression, Tantrums, Self-Injury

Risperidone is the atypical antipsychotic that has been studied most extensively in PDD. Open and controlled trials with risperidone have involved 223 patients with PDD. The Food and Drug Administration previously declared risperidone as nonapprovable for the treatment of autism in children, but it is now being submitted for approval for the treatment of tantrums, aggression, and self-injury, Dr. Scahill said.

In an 8-week, randomized, double-blind trial, risperidone significantly reduced aggressive behavior, tantrums, and self-injurious behavior by 57% in 49 children, compared with 14% in 52 children on placebo, according to the parent-rated irritability subscale of the Aberrant Behavior Checklist. Clinician ratings yielded similar results. The patients averaged 1.8 mg per day (N. Engl. J. Med. 2002;347:314–21).

During a 4-month open-label extension of the study for 63 responders to risperidone, irritability scores did not worsen, and patients did not require more risperidone to maintain their response (Am. J. Psychiatry 2005;162:1361–9). These responders gained an average of 5.6 kg during a total of 6 months of treatment with risperidone (Am. J. Psychiatry 2004;161:1125–7).

In a 2-month, randomized, double-blind discontinuation of risperidone, patients who continued to receive risperidone had a significantly lower rate of relapse (2 of 16) than did patients who gradually replaced risperidone with placebo (10 of 16).

ADHD Symptoms

Even though “we know that hyperactivity is a very common problem” in children and adolescents with PDD, “the evidence to support the use of methylphenidate in this population is frightfully little,” Dr. Scahill said.

Until recently, methylphenidate had been studied in only two trials of 10 children with PDD and ADHD. On the Conners Hyperactivity Index, teachers reported 11% improvement at a dose of 10–20 mg twice daily (J. Autism Dev. Disord. 1995;25:283–94), 32% improvement at 0.3 mg/kg per dose, and 47% improvement at 0.6 mg/kg (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:805–12).

In a more rigorous study of 66 children with PDD and hyperactivity conducted by Dr. Scahill and his colleagues, methylphenidate improved hyperactivity significantly but to a lesser degree than it would in typically developing children with ADHD, according to teacher and parent ratings (Arch. Gen. Psychiatry 2005;62:1266–74). Children in the randomized, double-blind, crossover trial tolerated three dose levels of methylphenidate during a 7-day test dose period and then received placebo for 1 week, followed by 3 weeks of the three methylphenidate doses in random order.

Thirty-four patients who responded to treatment based on a less conservative definition of response later received 8 weeks of open-label methylphenidate at an individually determined best dose. Adverse events such as decreased appetite and increased repetitive behavior and stereotypies occurred mainly with the highest dose, even though it was “not really that high” (0.5–0.6 mg/kg per dose), Dr. Scahill said. Few adverse events occurred in the 38% (25 of 66) of patients who responded to either the low (0.125–0.18 mg/kg per dose) or the medium dose (0.25–0.35 mg/kg per dose).

Liquid fluoxetine proved to be more effective in treating repetitive behaviors than placebo. DR. SCAHILL

NEW YORK – Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“It's pretty well established that children who receive stimulants, typically for [attention-deficit hyperactivity disorder], can have some slowing of their growth,” said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate. Pubertal development is normal.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, has a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake during stimulant use. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight at baseline, and children who use sustained-release medications.

Little data exist on the final adult height of children who have taken stimulants, Dr. Carlson said. Few studies have extended follow-up beyond 16 years of age for girls and 18 years for boys. In one study, 97 boys aged 4–12 years who were treated with methylphenidate for a mean of 36 months grew to a final adult height at 21–23 years of age that was similar to the final adult height of other males in their family, their community, and unmedicated controls. These data are “reassuring,” Dr. Carlson said, but “we want to emphasize that there may well be a subset of children who do have more significant slowing of growth.”

Dr. Carlson recommended obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months during treatment. A decrease of more than one standard deviation in height for age during treatment should prompt consultation to exclude other disorders such as hypothyroidism or gastrointestinal diseases.

NEW YORK – Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“It's pretty well established that children who receive stimulants, typically for [attention-deficit hyperactivity disorder], can have some slowing of their growth,” said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate. Pubertal development is normal.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, has a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake during stimulant use. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight at baseline, and children who use sustained-release medications.

Little data exist on the final adult height of children who have taken stimulants, Dr. Carlson said. Few studies have extended follow-up beyond 16 years of age for girls and 18 years for boys. In one study, 97 boys aged 4–12 years who were treated with methylphenidate for a mean of 36 months grew to a final adult height at 21–23 years of age that was similar to the final adult height of other males in their family, their community, and unmedicated controls. These data are “reassuring,” Dr. Carlson said, but “we want to emphasize that there may well be a subset of children who do have more significant slowing of growth.”

Dr. Carlson recommended obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months during treatment. A decrease of more than one standard deviation in height for age during treatment should prompt consultation to exclude other disorders such as hypothyroidism or gastrointestinal diseases.

NEW YORK – Significant growth slowdown during treatment with stimulants may occur in a small subset of children who require closer monitoring and referral, Dr. Harold E. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

“It's pretty well established that children who receive stimulants, typically for [attention-deficit hyperactivity disorder], can have some slowing of their growth,” said Dr. Carlson, head of endocrinology at the State University of New York at Stony Brook.

Height velocity, or yearly growth, typically slows for the first few years of stimulant therapy and then resumes at a nearly normal rate. Pubertal development is normal.

Final adult height is usually normal with long-term use of stimulants. However, a small subset of patients, perhaps 10%, has a more significant slowdown of growth, Dr. Carlson said.

“I don't think anybody has a good handle on how many [children experience this significant slowdown], and we certainly don't have a good idea as to how to identify them ahead of time,” he said.

Because the secretion of growth hormone in these children is normal, researchers have speculated that the slowdown may be related to a decrease in food intake during stimulant use. “That's probably it,” Dr. Carlson suggested, because “people on stimulants, especially on higher doses, often lose their appetite.”

The slowdown of growth is greater in prepubertal children, boys, children who are taller or overweight at baseline, and children who use sustained-release medications.

Little data exist on the final adult height of children who have taken stimulants, Dr. Carlson said. Few studies have extended follow-up beyond 16 years of age for girls and 18 years for boys. In one study, 97 boys aged 4–12 years who were treated with methylphenidate for a mean of 36 months grew to a final adult height at 21–23 years of age that was similar to the final adult height of other males in their family, their community, and unmedicated controls. These data are “reassuring,” Dr. Carlson said, but “we want to emphasize that there may well be a subset of children who do have more significant slowing of growth.”

Dr. Carlson recommended obtaining prior growth records and measuring the height and weight of children before beginning stimulants. Height and weight should be measured and plotted every 6 months during treatment. A decrease of more than one standard deviation in height for age during treatment should prompt consultation to exclude other disorders such as hypothyroidism or gastrointestinal diseases.