Miriam E. Tucker

WASHINGTON — Even parents who don't trust vaccines might let you vaccinate their children if they trust you.

That was the conclusion drawn from a survey of parents of 7,810 children aged 19–35 months from the 2001–2002 National Immunization Survey, conducted by Philip J. Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention's National Immunization Program, in Atlanta.

The majority of parents (77%) said they believed vaccines were safe and that their belief was influenced by their child's healthcare provider (physician, nurse, or other). However, 5.7% of parents reported believing that vaccines were not safe, with 2% saying they were not influenced by their child's healthcare provider and the 3.7% reporting that they were.

Another 17.2% said that they believed vaccines were safe but their belief was not influenced by a healthcare provider. This group is of concern, because “One thing we don't want to happen is that these parents' opinions migrate to the other side,” Dr. Smith said at the annual meeting of the American Academy of Pediatrics.

Parents who were not influenced by a healthcare provider were significantly more likely to say that vaccines were not safe, compared with parents who were so influenced (10.4% vs. 4.6%).

Somewhat surprising, however, were the up-to-date immunization rates among the children of the parents who believe that immunizations are not safe: 71.5% for those who said they were influenced by a healthcare provider, compared with just 55.8% of those who were not, a highly significant difference. “All this is pointing to the importance of a healthcare provider talking with the parent,” Dr. Smith said.

Indeed, earlier this year the American Academy of Pediatrics published guidelines on how to respond to parental refusal of immunization for their children (Pediatrics 2005;115:1428–31). Among AAP's recommendations are to listen respectfully to what the parents have to say and not minimize their concerns. Be honest about the benefits and risks of immunization, correct any misconceptions or misinformation, and refer the parents to trusted sources such as the CDC's National Immunization Program page (www.cdc.gov/nip

WASHINGTON — Even parents who don't trust vaccines might let you vaccinate their children if they trust you.

That was the conclusion drawn from a survey of parents of 7,810 children aged 19–35 months from the 2001–2002 National Immunization Survey, conducted by Philip J. Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention's National Immunization Program, in Atlanta.

The majority of parents (77%) said they believed vaccines were safe and that their belief was influenced by their child's healthcare provider (physician, nurse, or other). However, 5.7% of parents reported believing that vaccines were not safe, with 2% saying they were not influenced by their child's healthcare provider and the 3.7% reporting that they were.

Another 17.2% said that they believed vaccines were safe but their belief was not influenced by a healthcare provider. This group is of concern, because “One thing we don't want to happen is that these parents' opinions migrate to the other side,” Dr. Smith said at the annual meeting of the American Academy of Pediatrics.

Parents who were not influenced by a healthcare provider were significantly more likely to say that vaccines were not safe, compared with parents who were so influenced (10.4% vs. 4.6%).

Somewhat surprising, however, were the up-to-date immunization rates among the children of the parents who believe that immunizations are not safe: 71.5% for those who said they were influenced by a healthcare provider, compared with just 55.8% of those who were not, a highly significant difference. “All this is pointing to the importance of a healthcare provider talking with the parent,” Dr. Smith said.

Indeed, earlier this year the American Academy of Pediatrics published guidelines on how to respond to parental refusal of immunization for their children (Pediatrics 2005;115:1428–31). Among AAP's recommendations are to listen respectfully to what the parents have to say and not minimize their concerns. Be honest about the benefits and risks of immunization, correct any misconceptions or misinformation, and refer the parents to trusted sources such as the CDC's National Immunization Program page (www.cdc.gov/nip

WASHINGTON — Even parents who don't trust vaccines might let you vaccinate their children if they trust you.

That was the conclusion drawn from a survey of parents of 7,810 children aged 19–35 months from the 2001–2002 National Immunization Survey, conducted by Philip J. Smith, Ph.D., and his associates at the Centers for Disease Control and Prevention's National Immunization Program, in Atlanta.

The majority of parents (77%) said they believed vaccines were safe and that their belief was influenced by their child's healthcare provider (physician, nurse, or other). However, 5.7% of parents reported believing that vaccines were not safe, with 2% saying they were not influenced by their child's healthcare provider and the 3.7% reporting that they were.

Another 17.2% said that they believed vaccines were safe but their belief was not influenced by a healthcare provider. This group is of concern, because “One thing we don't want to happen is that these parents' opinions migrate to the other side,” Dr. Smith said at the annual meeting of the American Academy of Pediatrics.

Parents who were not influenced by a healthcare provider were significantly more likely to say that vaccines were not safe, compared with parents who were so influenced (10.4% vs. 4.6%).

Somewhat surprising, however, were the up-to-date immunization rates among the children of the parents who believe that immunizations are not safe: 71.5% for those who said they were influenced by a healthcare provider, compared with just 55.8% of those who were not, a highly significant difference. “All this is pointing to the importance of a healthcare provider talking with the parent,” Dr. Smith said.

Indeed, earlier this year the American Academy of Pediatrics published guidelines on how to respond to parental refusal of immunization for their children (Pediatrics 2005;115:1428–31). Among AAP's recommendations are to listen respectfully to what the parents have to say and not minimize their concerns. Be honest about the benefits and risks of immunization, correct any misconceptions or misinformation, and refer the parents to trusted sources such as the CDC's National Immunization Program page (www.cdc.gov/nip

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons. In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were other specialties, while orthopedic surgeons were least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious. Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice more than 6 years and who practice in urban, academic settings, Dr. Karas and her associates reported.

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons. In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were other specialties, while orthopedic surgeons were least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious. Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice more than 6 years and who practice in urban, academic settings, Dr. Karas and her associates reported.

WASHINGTON — Endocrinologists and rheumatologists are the most aggressive specialists when it comes to the screening, diagnosis, and treatment of osteoporosis, Tiffany Karas, M.D., and her associates reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.

Of 122 physicians who responded to an electronic survey, there were 27 geriatricians, 25 endocrinologists, 23 obstetrician/gynecologists, 20 rheumatologists, 19 primary care physicians, and 8 orthopedic surgeons. In screening for osteoporosis, 94% of the entire group said they would order a dual-energy x-ray absorptiometry (DXA) scan for a patient with two or more risk factors, said Dr. Karas and her associates, of Loyola University Medical Center, Maywood, Ill.

The risk factors most likely to prompt DXA scanning were height loss (93%), chronic prednisone use (89%), and menopause (86.6%). Among the risk factors least likely to prompt DXA were low testosterone (60%) and vertebral deformities (74%) in an elderly male patient. In general, all physicians surveyed were much less likely to order DXA for men with indications than for women. “This is one area where continuing education about osteoporosis may improve patient care,” the investigators noted.

Endocrinologists and rheumatologists were more likely to order DXA given any risk factor or patient scenario than were other specialties, while orthopedic surgeons were least likely. Rheumatologists were the most likely to initiate treatment in patients, followed by endocrinologists, geriatricians, primary care physicians, and ob.gyns.

Alendronate and risedronate were deemed the most efficacious treatments by more than 98% of all physicians, while calcium/vitamin D and calcitonin were thought to be the least efficacious. Overall, patients were more likely to be screened, diagnosed, and treated for osteoporosis by female physicians who had been in practice more than 6 years and who practice in urban, academic settings, Dr. Karas and her associates reported.

Less than half of overweight children in the United States are told that they are overweight by their physicians, the Centers for Disease Control and Prevention reported.

The percentage of children and teens aged 6–19 years who are overweight tripled to 16% during the period 1980–2002. Yet from 1999 to 2002, only 36.7% of children or their parents reported having been told by their physician or other health care provider that they were overweight. “By discussing weight status with overweight patients and their parents, pediatric health care providers might help these patients implement lifelong improvements in diet and physical activity,” the CDC said (MMWR 2005;54:848–9).

The data come from the National Health and Nutrition Examination Survey (NHANES), which sampled 1,473 children and teens aged 2–19 years determined to be overweight (greater than or equal to the 95th percentile of body mass index for age and sex in the year 2000).

Parents of children 2–11 years old were asked whether they had ever been told that the child was overweight. For 12- to 15-year-olds, the parent was asked if the child had been told that he/she was overweight.

And teens aged 16–19 years were themselves asked if they had ever been told they were overweight.

The proportion who had been told of their overweight status increased by age, from 17.4% for ages 2–5 years to 32.6% of those aged 6–11 years, to 39.6% for ages 12–15 years, to 51.6% of the adolescents aged 16–19 years.

Overweight black females were significantly more likely to be given the diagnosis than were overweight white females (47% vs. 31%). Among those who were informed of their overweight status, 39% of the black females were severely overweight, compared with 17% of the white females, the CDC reported.

Previous findings suggest that children begin to respond to environmental cues regarding dietary patterns by age 5 years. “Thus, early recognition and discussion of overweight status is a necessary first step to developing healthier lifelong behaviors,” the CDC noted.

Less than half of overweight children in the United States are told that they are overweight by their physicians, the Centers for Disease Control and Prevention reported.

The percentage of children and teens aged 6–19 years who are overweight tripled to 16% during the period 1980–2002. Yet from 1999 to 2002, only 36.7% of children or their parents reported having been told by their physician or other health care provider that they were overweight. “By discussing weight status with overweight patients and their parents, pediatric health care providers might help these patients implement lifelong improvements in diet and physical activity,” the CDC said (MMWR 2005;54:848–9).

The data come from the National Health and Nutrition Examination Survey (NHANES), which sampled 1,473 children and teens aged 2–19 years determined to be overweight (greater than or equal to the 95th percentile of body mass index for age and sex in the year 2000).

Parents of children 2–11 years old were asked whether they had ever been told that the child was overweight. For 12- to 15-year-olds, the parent was asked if the child had been told that he/she was overweight.

And teens aged 16–19 years were themselves asked if they had ever been told they were overweight.

The proportion who had been told of their overweight status increased by age, from 17.4% for ages 2–5 years to 32.6% of those aged 6–11 years, to 39.6% for ages 12–15 years, to 51.6% of the adolescents aged 16–19 years.

Overweight black females were significantly more likely to be given the diagnosis than were overweight white females (47% vs. 31%). Among those who were informed of their overweight status, 39% of the black females were severely overweight, compared with 17% of the white females, the CDC reported.

Previous findings suggest that children begin to respond to environmental cues regarding dietary patterns by age 5 years. “Thus, early recognition and discussion of overweight status is a necessary first step to developing healthier lifelong behaviors,” the CDC noted.

Less than half of overweight children in the United States are told that they are overweight by their physicians, the Centers for Disease Control and Prevention reported.

The percentage of children and teens aged 6–19 years who are overweight tripled to 16% during the period 1980–2002. Yet from 1999 to 2002, only 36.7% of children or their parents reported having been told by their physician or other health care provider that they were overweight. “By discussing weight status with overweight patients and their parents, pediatric health care providers might help these patients implement lifelong improvements in diet and physical activity,” the CDC said (MMWR 2005;54:848–9).

The data come from the National Health and Nutrition Examination Survey (NHANES), which sampled 1,473 children and teens aged 2–19 years determined to be overweight (greater than or equal to the 95th percentile of body mass index for age and sex in the year 2000).

Parents of children 2–11 years old were asked whether they had ever been told that the child was overweight. For 12- to 15-year-olds, the parent was asked if the child had been told that he/she was overweight.

And teens aged 16–19 years were themselves asked if they had ever been told they were overweight.

The proportion who had been told of their overweight status increased by age, from 17.4% for ages 2–5 years to 32.6% of those aged 6–11 years, to 39.6% for ages 12–15 years, to 51.6% of the adolescents aged 16–19 years.

Overweight black females were significantly more likely to be given the diagnosis than were overweight white females (47% vs. 31%). Among those who were informed of their overweight status, 39% of the black females were severely overweight, compared with 17% of the white females, the CDC reported.

Previous findings suggest that children begin to respond to environmental cues regarding dietary patterns by age 5 years. “Thus, early recognition and discussion of overweight status is a necessary first step to developing healthier lifelong behaviors,” the CDC noted.

SAN DIEGO — One-fourth of children with diabetes present with ketoacidosis at onset, and a majority are hospitalized, Arleta B. Rewers, M.D., reported at the annual scientific sessions of the American Diabetes Association.

Younger and poorer children are more likely to present with diabetic ketoacidosis (DKA), according to a study of 824 children and adolescents younger than 20 years of age who were diagnosed with diabetes in 2002 in four U.S. geographical areas and two large HMOs, said Dr. Rewers, an emergency physician at the Children's Hospital, Denver.

Of the 824 children with new-onset diabetes, 57% were hospitalized while just 12% had an emergency department visit only. Diabetic ketoacidosis, defined as a bicarbonate level of less than 15 mmol/L and/or a pH less than 7.25 (or less than 7.3 if arterial or capillary blood was obtained), was present in 24%. No significant differences in DKA rates by gender or race/ethnicity were found, Dr. Rewers reported.

The proportion presenting with DKA decreased significantly with increasing age, from 36% of children aged 0–4 years down to 16.5% of adolescents aged 15–19 years. Among those diagnosed as having type 1 diabetes, the prevalence of DKA was 28%, more than double the prevalence in children diagnosed with type 2 diabetes (13%) or an unknown type (12%).

Lower parental income and lower parental educational achievement were significantly associated with an increased likelihood of the child presenting with DKA.

After adjustment for clinic, gender, race/ethnicity, diabetes type, and insurance coverage, children aged 0–4 years were 5.6 times more likely than older children to present with DKA, while those with annual family incomes less than $55,000 had a risk for DKA that was five times greater than that of children whose parents made between $75,000 and $100,000 a year, she said.

Source: Dr. Yusuf

SAN DIEGO — One-fourth of children with diabetes present with ketoacidosis at onset, and a majority are hospitalized, Arleta B. Rewers, M.D., reported at the annual scientific sessions of the American Diabetes Association.

Younger and poorer children are more likely to present with diabetic ketoacidosis (DKA), according to a study of 824 children and adolescents younger than 20 years of age who were diagnosed with diabetes in 2002 in four U.S. geographical areas and two large HMOs, said Dr. Rewers, an emergency physician at the Children's Hospital, Denver.

Of the 824 children with new-onset diabetes, 57% were hospitalized while just 12% had an emergency department visit only. Diabetic ketoacidosis, defined as a bicarbonate level of less than 15 mmol/L and/or a pH less than 7.25 (or less than 7.3 if arterial or capillary blood was obtained), was present in 24%. No significant differences in DKA rates by gender or race/ethnicity were found, Dr. Rewers reported.

The proportion presenting with DKA decreased significantly with increasing age, from 36% of children aged 0–4 years down to 16.5% of adolescents aged 15–19 years. Among those diagnosed as having type 1 diabetes, the prevalence of DKA was 28%, more than double the prevalence in children diagnosed with type 2 diabetes (13%) or an unknown type (12%).

Lower parental income and lower parental educational achievement were significantly associated with an increased likelihood of the child presenting with DKA.

After adjustment for clinic, gender, race/ethnicity, diabetes type, and insurance coverage, children aged 0–4 years were 5.6 times more likely than older children to present with DKA, while those with annual family incomes less than $55,000 had a risk for DKA that was five times greater than that of children whose parents made between $75,000 and $100,000 a year, she said.

Source: Dr. Yusuf

SAN DIEGO — One-fourth of children with diabetes present with ketoacidosis at onset, and a majority are hospitalized, Arleta B. Rewers, M.D., reported at the annual scientific sessions of the American Diabetes Association.

Younger and poorer children are more likely to present with diabetic ketoacidosis (DKA), according to a study of 824 children and adolescents younger than 20 years of age who were diagnosed with diabetes in 2002 in four U.S. geographical areas and two large HMOs, said Dr. Rewers, an emergency physician at the Children's Hospital, Denver.

Of the 824 children with new-onset diabetes, 57% were hospitalized while just 12% had an emergency department visit only. Diabetic ketoacidosis, defined as a bicarbonate level of less than 15 mmol/L and/or a pH less than 7.25 (or less than 7.3 if arterial or capillary blood was obtained), was present in 24%. No significant differences in DKA rates by gender or race/ethnicity were found, Dr. Rewers reported.

The proportion presenting with DKA decreased significantly with increasing age, from 36% of children aged 0–4 years down to 16.5% of adolescents aged 15–19 years. Among those diagnosed as having type 1 diabetes, the prevalence of DKA was 28%, more than double the prevalence in children diagnosed with type 2 diabetes (13%) or an unknown type (12%).

Lower parental income and lower parental educational achievement were significantly associated with an increased likelihood of the child presenting with DKA.

After adjustment for clinic, gender, race/ethnicity, diabetes type, and insurance coverage, children aged 0–4 years were 5.6 times more likely than older children to present with DKA, while those with annual family incomes less than $55,000 had a risk for DKA that was five times greater than that of children whose parents made between $75,000 and $100,000 a year, she said.

Source: Dr. Yusuf

SAN DIEGO — Deaths from diabetic ketoacidosis among adults in the United States decreased by one-third between 1984 and 2002, Jing Wang and her associates reported in a poster at the annual scientific sessions of the American Diabetes Association.

There was no decline, however, in diabetic ketoacidosis (DKA) deaths among black men, and a large proportion of DKA deaths continue to occur at home or prior to arrival at the emergency department, said Ms. Wang, a health care analyst with Northrop Grumman/Information Technology, supporting the division of diabetes translation at the Centers for Disease Control and Prevention, Atlanta.

The data were derived from vital records of patients with diabetes seen in 1984–1998 using ICD-9 codes and in 1999–2002 using ICD-10 codes. Estimates of the U.S. diabetic population came from the National Health Interview Survey.

Between 1984 and 2002, the age-adjusted DKA death rate dropped from 30.5 to 20.5 per 100,000 diabetics. Declines occurred in all age groups, ranging from a 65% drop among individuals aged 65 and older to a 22% drop among those aged 18–44.

Age-adjusted DKA death rates declined by 18% among white men, 35% among white women, and 46% among black women. The rates for black men, on the other hand, remained essentially unchanged, averaging at least twice that of the other groups, the investigators noted.

In 2002, 52% of DKA deaths occurred in the hospital, 12% in emergency departments/outpatient clinics, 26% at a residence, and 10% in other places.

From 1992 (the first year for which place-of-death data were available) through 2002, DKA death rates declined in all health care sites, dropping by 49% in hospitals, 38% in emergency departments/outpatient clinics, and 59% in nursing homes. For all health care sites combined, the DKA death rate dropped from 19 to 10.3 per 100,000 from 1992 to 2002.

However, the rate of DKA deaths occurring at the patient's residence remained essentially unchanged between 1992 (3.5/100,000) and 2002 (3.7/100,000).

The number of DKA deaths still occurring at home is of concern, particularly since the condition is both preventable and treatable. “A better understanding of how to prevent their occurrence is essential,” the investigators wrote.

SAN DIEGO — Deaths from diabetic ketoacidosis among adults in the United States decreased by one-third between 1984 and 2002, Jing Wang and her associates reported in a poster at the annual scientific sessions of the American Diabetes Association.

There was no decline, however, in diabetic ketoacidosis (DKA) deaths among black men, and a large proportion of DKA deaths continue to occur at home or prior to arrival at the emergency department, said Ms. Wang, a health care analyst with Northrop Grumman/Information Technology, supporting the division of diabetes translation at the Centers for Disease Control and Prevention, Atlanta.

The data were derived from vital records of patients with diabetes seen in 1984–1998 using ICD-9 codes and in 1999–2002 using ICD-10 codes. Estimates of the U.S. diabetic population came from the National Health Interview Survey.

Between 1984 and 2002, the age-adjusted DKA death rate dropped from 30.5 to 20.5 per 100,000 diabetics. Declines occurred in all age groups, ranging from a 65% drop among individuals aged 65 and older to a 22% drop among those aged 18–44.

Age-adjusted DKA death rates declined by 18% among white men, 35% among white women, and 46% among black women. The rates for black men, on the other hand, remained essentially unchanged, averaging at least twice that of the other groups, the investigators noted.

In 2002, 52% of DKA deaths occurred in the hospital, 12% in emergency departments/outpatient clinics, 26% at a residence, and 10% in other places.

From 1992 (the first year for which place-of-death data were available) through 2002, DKA death rates declined in all health care sites, dropping by 49% in hospitals, 38% in emergency departments/outpatient clinics, and 59% in nursing homes. For all health care sites combined, the DKA death rate dropped from 19 to 10.3 per 100,000 from 1992 to 2002.

However, the rate of DKA deaths occurring at the patient's residence remained essentially unchanged between 1992 (3.5/100,000) and 2002 (3.7/100,000).

The number of DKA deaths still occurring at home is of concern, particularly since the condition is both preventable and treatable. “A better understanding of how to prevent their occurrence is essential,” the investigators wrote.

SAN DIEGO — Deaths from diabetic ketoacidosis among adults in the United States decreased by one-third between 1984 and 2002, Jing Wang and her associates reported in a poster at the annual scientific sessions of the American Diabetes Association.

There was no decline, however, in diabetic ketoacidosis (DKA) deaths among black men, and a large proportion of DKA deaths continue to occur at home or prior to arrival at the emergency department, said Ms. Wang, a health care analyst with Northrop Grumman/Information Technology, supporting the division of diabetes translation at the Centers for Disease Control and Prevention, Atlanta.

The data were derived from vital records of patients with diabetes seen in 1984–1998 using ICD-9 codes and in 1999–2002 using ICD-10 codes. Estimates of the U.S. diabetic population came from the National Health Interview Survey.

Between 1984 and 2002, the age-adjusted DKA death rate dropped from 30.5 to 20.5 per 100,000 diabetics. Declines occurred in all age groups, ranging from a 65% drop among individuals aged 65 and older to a 22% drop among those aged 18–44.

Age-adjusted DKA death rates declined by 18% among white men, 35% among white women, and 46% among black women. The rates for black men, on the other hand, remained essentially unchanged, averaging at least twice that of the other groups, the investigators noted.

In 2002, 52% of DKA deaths occurred in the hospital, 12% in emergency departments/outpatient clinics, 26% at a residence, and 10% in other places.

From 1992 (the first year for which place-of-death data were available) through 2002, DKA death rates declined in all health care sites, dropping by 49% in hospitals, 38% in emergency departments/outpatient clinics, and 59% in nursing homes. For all health care sites combined, the DKA death rate dropped from 19 to 10.3 per 100,000 from 1992 to 2002.

However, the rate of DKA deaths occurring at the patient's residence remained essentially unchanged between 1992 (3.5/100,000) and 2002 (3.7/100,000).

The number of DKA deaths still occurring at home is of concern, particularly since the condition is both preventable and treatable. “A better understanding of how to prevent their occurrence is essential,” the investigators wrote.

More than half of all the measles cases reported among United States residents during 2001–2004 were preventable, according to the Centers for Disease Control and Prevention.

Although endemic measles has been eliminated from the United States, cases continue to be imported from other parts of the world, and infected travelers can transmit the disease to susceptible contacts, the CDC said (MMWR 2005;54:817–20).

Of the 251 measles cases reported to the CDC during 2001–2004, 71% occurred among U.S. residents and 29% among nonresidents. Of the 177 cases among U.S. residents, 100 (56%) were considered preventable, meaning that they occurred in persons for whom vaccination against measles is recommended by the Advisory Committee on Immunization Practices, but those individuals had not received 1 or more doses of measles-containing vaccine.

Among the 177 U.S. residents, 52% (92) were aged 0–19 years and 48% (85) were aged 20 years or older. Nearly one-third (31%) had traveled abroad, while the other 69% were infected in the United States. More than three-fourths (77%) of the total group had not been vaccinated. Of those 136, only 7 cases (5%) were considered not preventable, because the individuals were born before 1957 and vaccination is not recommended for that age group.

Current recommendations for travelers include vaccination for infants 6–11 months of age and two doses of measles-containing vaccine for travelers aged 12 months and above. Yet the 100 preventable cases in this report included a total of 43 travelers: 17 infants aged 6–15 months, 11 children and adolescents aged 16 months to 19 years, and 15 adults aged 20 and older.

One of these cases was an 11-year-old girl who developed a rash 3 days after returning to the United States from the United Kingdom. She had close contact with an 11-month-old infant, who subsequently had contact with up to 234 persons at a summer camp 2 days before he also developed a rash. Thanks to extensive investigation and control efforts, no further cases were subsequently identified.

Measles cases among persons born before 1957 are rare. However, individuals in this age group who travel internationally might wish to consider vaccination, the CDC advised. Information on vaccination recommendations for travelers is available at www.cdc.gov/travel

More than half of all the measles cases reported among United States residents during 2001–2004 were preventable, according to the Centers for Disease Control and Prevention.

Although endemic measles has been eliminated from the United States, cases continue to be imported from other parts of the world, and infected travelers can transmit the disease to susceptible contacts, the CDC said (MMWR 2005;54:817–20).

Of the 251 measles cases reported to the CDC during 2001–2004, 71% occurred among U.S. residents and 29% among nonresidents. Of the 177 cases among U.S. residents, 100 (56%) were considered preventable, meaning that they occurred in persons for whom vaccination against measles is recommended by the Advisory Committee on Immunization Practices, but those individuals had not received 1 or more doses of measles-containing vaccine.

Among the 177 U.S. residents, 52% (92) were aged 0–19 years and 48% (85) were aged 20 years or older. Nearly one-third (31%) had traveled abroad, while the other 69% were infected in the United States. More than three-fourths (77%) of the total group had not been vaccinated. Of those 136, only 7 cases (5%) were considered not preventable, because the individuals were born before 1957 and vaccination is not recommended for that age group.

Current recommendations for travelers include vaccination for infants 6–11 months of age and two doses of measles-containing vaccine for travelers aged 12 months and above. Yet the 100 preventable cases in this report included a total of 43 travelers: 17 infants aged 6–15 months, 11 children and adolescents aged 16 months to 19 years, and 15 adults aged 20 and older.

One of these cases was an 11-year-old girl who developed a rash 3 days after returning to the United States from the United Kingdom. She had close contact with an 11-month-old infant, who subsequently had contact with up to 234 persons at a summer camp 2 days before he also developed a rash. Thanks to extensive investigation and control efforts, no further cases were subsequently identified.

Measles cases among persons born before 1957 are rare. However, individuals in this age group who travel internationally might wish to consider vaccination, the CDC advised. Information on vaccination recommendations for travelers is available at www.cdc.gov/travel

More than half of all the measles cases reported among United States residents during 2001–2004 were preventable, according to the Centers for Disease Control and Prevention.

Although endemic measles has been eliminated from the United States, cases continue to be imported from other parts of the world, and infected travelers can transmit the disease to susceptible contacts, the CDC said (MMWR 2005;54:817–20).

Of the 251 measles cases reported to the CDC during 2001–2004, 71% occurred among U.S. residents and 29% among nonresidents. Of the 177 cases among U.S. residents, 100 (56%) were considered preventable, meaning that they occurred in persons for whom vaccination against measles is recommended by the Advisory Committee on Immunization Practices, but those individuals had not received 1 or more doses of measles-containing vaccine.

Among the 177 U.S. residents, 52% (92) were aged 0–19 years and 48% (85) were aged 20 years or older. Nearly one-third (31%) had traveled abroad, while the other 69% were infected in the United States. More than three-fourths (77%) of the total group had not been vaccinated. Of those 136, only 7 cases (5%) were considered not preventable, because the individuals were born before 1957 and vaccination is not recommended for that age group.

Current recommendations for travelers include vaccination for infants 6–11 months of age and two doses of measles-containing vaccine for travelers aged 12 months and above. Yet the 100 preventable cases in this report included a total of 43 travelers: 17 infants aged 6–15 months, 11 children and adolescents aged 16 months to 19 years, and 15 adults aged 20 and older.

One of these cases was an 11-year-old girl who developed a rash 3 days after returning to the United States from the United Kingdom. She had close contact with an 11-month-old infant, who subsequently had contact with up to 234 persons at a summer camp 2 days before he also developed a rash. Thanks to extensive investigation and control efforts, no further cases were subsequently identified.

Measles cases among persons born before 1957 are rare. However, individuals in this age group who travel internationally might wish to consider vaccination, the CDC advised. Information on vaccination recommendations for travelers is available at www.cdc.gov/travel

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

The dramatic rise in obesity over the last decade has heightened debate among psychiatrists about whether “binge eating disorder” is a distinct clinical entity that deserves to move from the appendix of the DSM-IV up to a full-fledged psychiatric diagnosis in the DSM-V.

Since the DSM-IV was published in 1994, the prevalence of obesity among adults in the United States has risen by at least 30%. One-third of the U.S. population is currently considered obese, with a body mass index of 30 kg/m2 or greater, and more than two-thirds are overweight, with BMIs at or above 25.

Largely hidden in these statistics are roughly 2% of the population who meet the proposed binge eating disorder (BED) criteria (See box)–and who make up about one-third of individuals who seek help in weight loss treatment programs–as well as the unknown but undoubtedly huge number of people who don't meet the BED criteria but exhibit abnormal eating behavior linked to negative emotional states.

“There's a lot of interest in this topic, much of it related to how the fields of behavioral medicine and psychiatry can make a contribution to both the understanding and treatment of obesity,” said B. Timothy Walsh, M.D., who chaired the DSM-IV committee on eating disorders.

The term “binge eating disorder” is widely used in research and clinical settings, but BED is not an official diagnostic category. It is included in the DSM-IV under “criteria sets and axes for further study.” Patients who now meet the definition are classified either by other comorbid conditions such as depression or anxiety, and/or under the heading of “eating disorders not otherwise specified” (EDNOS).

The EDNOS category has proved problematic, because it lumps BED in the same category with a young woman who meets all the criteria for anorexia nervosa except that she still menstruates. It also refers to the patient who binges and purges but not quite often enough to qualify for bulimia nervosa. “There's been a lot of discussion about how to handle the EDNOS issue. It's a heterogeneous mix,” noted Dr. Walsh, director of the eating disorders research unit at New York State Psychiatric Institute/Columbia University, New York.

And BED patients are demographically very different from those with either anorexia or bulimia. They tend to be middle-aged at the time of diagnosis as opposed to an adolescent or young adult, and are as likely to be black or Hispanic as white, while patients with the other common eating disorders are primarily white. And, although BED is seen more often in women than in men, the ratio is about 60/40, compared with the 90/10 female/male ratio seen with anorexia and bulimia.

So, although BED is a distinct entity–these patients eat more in a shorter period of time than do other obese individuals–the primary reason that it didn't make it into DSM-IV is that “there are not compelling data that people who meet the criteria have a different need for treatment and/or a different prognosis than people who could be described equally well by existing categories. That evidence is still lacking,” Dr. Walsh said.

“The fact that most people with BED are obese, and most have some symptoms of anxiety or depression makes one wonder if those labels aren't sufficient. I don't think we should be casual about applying labels. We have to be rigorous in our insistence that the evidence backs up the utility of labels, because once they get created and formally approved, it's very hard to erase them,” he remarked.

Carlos M. Grilo, Ph.D., professor of psychiatry and director of the eating disorders program at Yale University, New Haven, Conn., agrees. “There is still active debate about the BED term. There is a clinical reality: Patients do suffer from problems described by the term. The research shows that persons who binge eat have increased psychiatric problems and psychological distress. But, do they benefit less from obesity treatment programs than do obese individuals who don't binge eat? That's not clear.”

Indeed, the only clear conclusion about BED treatment is that both cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) effectively reduce binge eating behavior. Both seem to work equally well, although more data are available for CBT. In one randomized comparison of CBT and IPT conducted in group settings for 20 weeks, binge eating recovery rates were equivalent among 81 patients in each group: 64 (79%) with CBT, compared with 59 (73%) with IPT post treatment. At 1 year follow-up, 59% who received CBT and 62% with IPT were still in remission (Arch. Gen. Psychiatry 2002;59:713–21).

But neither CBT nor IPT alone has proven useful for weight loss. Thus far, however, adding concurrent pharmacologic agents or other therapeutic modalities to CBT has yielded inconsistent results.

In a recent randomized, placebo-controlled study by Dr. Grilo and his associates, CBT was significantly superior to fluoxetine, and the addition of fluoxetine to CBT did not produce any further benefit than did the addition of placebo to CBT in either binge eating behavior or weight loss among 108 patients (Biol. Psychiatry 2005;57:301–9).

In an older randomized study that compared the addition of fluoxetine or placebo to behavior modification in 45 obese subjects–22 with binge eating problems and 23 without–weight loss was significantly greater among those taking fluoxetine, but the results did not differ between the binge eaters and the nonbinge eaters (Am. J. Psychiatry 1990;147:876–81).

In another of Dr. Grilo's recent studies, 50 obese BED patients on guided self-help CBT were randomized to receive 12-week concurrent treatment with either 120 mg orlistat three times a day or placebo. In the intent-to-treat analysis, 36% of the orlistat group achieved weight loss of 5% or greater, compared with just 8% of the placebo group. At 3 months' follow-up, those rates were 32% and 8%, with comparable rates of improvement in both eating disorder psychopathology and psychological distress (Biol. Psychiatry 2005;57:1193–201).

Studies of sibutramine (Meridia), an antiobesity medication (Arch. Gen. Psychiatry 2003;60:1109–16), and the antiepileptic topiramate (Topamax) have also shown significant reductions in binge eating and weight loss compared with placebo, although the latter had a high discontinuation rate (J. Clin. Psychiatry 2004;65:1463–9).

Finally, recent data have reinforced the benefits of guided self-help CBT over guided self-help behavioral weight loss (BWL) programs in reducing the frequency of binge eating (Behav. Res. Ther. 2005;43:1509–25) and of individual CBT in reducing binge eating behavior, compared with those who did not receive CBT among 116 overweight/obese BED patients who all received BWL treatment over 20 weeks (Obes. Res. 2005;13:1077–88).

“It's very clear that CBT is the best available treatment for obese persons who binge eat,” Dr. Grilo said. “It's superior to medications and behavioral weight loss in producing remission in binging and improving psychological profile. But, it does not appear to be useful for weight loss. Adding orlistat might be one way to go, but we need more data.”

But Dr. Walsh pointed out, there are no data looking at the efficacy of commercial weight loss programs such as Weight Watchers in people who meet the BED criteria. “Do they really need CBT, or are standard weight loss programs just as good? That's a very important question.”

Dr. Grilo and Dr. Walsh think the answers might come from two particular ongoing studies, both funded by the National Institutes of Health. One, being conducted at Washington University in St. Louis, is looking at the long-term impact of 24 weeks' treatment with the three major psychological approaches (CBT, interpersonal therapy, and behavioral weight loss) in BED. The other trial, from Dr. Grilo's group, is comparing CBT and BWL (“dieting”) separately and also in sequence to see whether CBT followed by BWL is effective in reducing both binge eating and weight for up to 1 year post treatment.

Data from both studies are expected in mid-2007.

DSM-IV Research Criteria for BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

(2) eating until feeling uncomfortably full

(3) eating large amounts of food when not feeling physically hungry

(4) eating alone because of being embarrassed by how much one is eating

(5) feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Source: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision

WASHINGTON — Although there are gaps in the literature about the psychosocial aspects of diabetes management, evidence-based strategies do tend to work for many patients, Leonard Jack Jr., Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

A major review of 84 published articles pertaining to diabetes self-management training found that, overall, evidence supports the efficacy of such training for patients with type 2 diabetes, particularly in the short term.

The authors concluded that further research is needed to assess the effects of self-management interventions on sustained glycemic control; cardiovascular disease risk factors; and, ultimately, microvascular disease and quality of life (Diabetes Care 2001;24:561–87).

The literature is inadequate in many areas, including details about the interventions, assessment of patient satisfaction, the influence of family on patient outcomes, and the particular impact of diabetes self-management interventions on men.

Nearly all the published studies are comprised mostly of female patients, noted Dr. Jack, team leader of Applied Behavioral Research, Epidemiology, Surveillance, and Evaluation at the Centers for Disease Control and Prevention's division of diabetes translation, Atlanta.

Despite the gaps, the literature does support the following counseling strategies for all patients with diabetes:

▸ Frame the teaching to match the patient's perceptions. Simply by asking the question “When you think of diabetes, what do you think of?” can elicit the information needed to focus the teaching based on the patient's perceptions or misperceptions, he said.

▸ Fully inform patients of the purpose and expected effects of interventions—and when to expect these effects. This helps avoid discouragement when results are not immediate. If potential setbacks are likely, warn the patient of this and offer suggestions on what to do.

▸ Suggest small lifestyle changes rather than large ones. Patients can be asked to do just slightly more than they're doing now, such as adding 5 more minutes of walking if they're already doing 10. Many studies on self-efficacy suggest that enhancing a patient's faith in his or her capabilities improves the chances of success.

▸ Be specific. Tell the patient exactly how much to exercise, how often to eat, how intensely to work out, and explain the rationale for the recommendation. Demonstrate your instructions if possible, and write them down on a prescription sheet.

▸ Remember that it's easier to add new behaviors than to eliminate old ones. If weight loss is a goal, it may be more effective to suggest that they begin taking short walks or other light physical activity than to change their current eating patterns. In all studies, dietary habits are harder to change than anything else, Dr. Jack noted.

▸ Link new behaviors to old ones. Suggest that a patient exercise before eating lunch, or use an exercise bike while watching the evening news, or take his or her medication when brushing teeth. Family routine is important too—make sure that what you're telling the patient doesn't interfere with established family activities.

▸ Use the power of the profession. Don't be afraid to tell a patient outright to stop smoking, cut the fat out of the diet, get out of the house more often, or seek additional help.

▸ Get explicit commitments from patients. Ask patients to describe how they plan to follow the intended regimen. Ask them, “What specifically do you plan to do this upcoming week?” If the patient expresses uncertainty, try to brainstorm with him or her about the scenario and alternatives, Dr. Jack said.

▸ Use a combination of strategies. Individual counseling, group psychoeducation, written materials, and community resources will each work for some patients some of the time. Combining them improves the chances for success, he said.

▸ Involve your office staff. A multifaceted team approach, including a nurse, certified diabetes educator, dietitian/nutritionist, and others, is optimal for managing patients with diabetes.

▸ Refer patients with complex problems. Those with severe depression, psychosis, or suicidal ideation need expert help, as do those with less severe but still complicated problems such as difficulty with interpersonal relationships.

WASHINGTON — Although there are gaps in the literature about the psychosocial aspects of diabetes management, evidence-based strategies do tend to work for many patients, Leonard Jack Jr., Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

A major review of 84 published articles pertaining to diabetes self-management training found that, overall, evidence supports the efficacy of such training for patients with type 2 diabetes, particularly in the short term.

The authors concluded that further research is needed to assess the effects of self-management interventions on sustained glycemic control; cardiovascular disease risk factors; and, ultimately, microvascular disease and quality of life (Diabetes Care 2001;24:561–87).

The literature is inadequate in many areas, including details about the interventions, assessment of patient satisfaction, the influence of family on patient outcomes, and the particular impact of diabetes self-management interventions on men.

Nearly all the published studies are comprised mostly of female patients, noted Dr. Jack, team leader of Applied Behavioral Research, Epidemiology, Surveillance, and Evaluation at the Centers for Disease Control and Prevention's division of diabetes translation, Atlanta.

Despite the gaps, the literature does support the following counseling strategies for all patients with diabetes:

▸ Frame the teaching to match the patient's perceptions. Simply by asking the question “When you think of diabetes, what do you think of?” can elicit the information needed to focus the teaching based on the patient's perceptions or misperceptions, he said.

▸ Fully inform patients of the purpose and expected effects of interventions—and when to expect these effects. This helps avoid discouragement when results are not immediate. If potential setbacks are likely, warn the patient of this and offer suggestions on what to do.

▸ Suggest small lifestyle changes rather than large ones. Patients can be asked to do just slightly more than they're doing now, such as adding 5 more minutes of walking if they're already doing 10. Many studies on self-efficacy suggest that enhancing a patient's faith in his or her capabilities improves the chances of success.

▸ Be specific. Tell the patient exactly how much to exercise, how often to eat, how intensely to work out, and explain the rationale for the recommendation. Demonstrate your instructions if possible, and write them down on a prescription sheet.

▸ Remember that it's easier to add new behaviors than to eliminate old ones. If weight loss is a goal, it may be more effective to suggest that they begin taking short walks or other light physical activity than to change their current eating patterns. In all studies, dietary habits are harder to change than anything else, Dr. Jack noted.

▸ Link new behaviors to old ones. Suggest that a patient exercise before eating lunch, or use an exercise bike while watching the evening news, or take his or her medication when brushing teeth. Family routine is important too—make sure that what you're telling the patient doesn't interfere with established family activities.

▸ Use the power of the profession. Don't be afraid to tell a patient outright to stop smoking, cut the fat out of the diet, get out of the house more often, or seek additional help.

▸ Get explicit commitments from patients. Ask patients to describe how they plan to follow the intended regimen. Ask them, “What specifically do you plan to do this upcoming week?” If the patient expresses uncertainty, try to brainstorm with him or her about the scenario and alternatives, Dr. Jack said.

▸ Use a combination of strategies. Individual counseling, group psychoeducation, written materials, and community resources will each work for some patients some of the time. Combining them improves the chances for success, he said.

▸ Involve your office staff. A multifaceted team approach, including a nurse, certified diabetes educator, dietitian/nutritionist, and others, is optimal for managing patients with diabetes.

▸ Refer patients with complex problems. Those with severe depression, psychosis, or suicidal ideation need expert help, as do those with less severe but still complicated problems such as difficulty with interpersonal relationships.

WASHINGTON — Although there are gaps in the literature about the psychosocial aspects of diabetes management, evidence-based strategies do tend to work for many patients, Leonard Jack Jr., Ph.D., said at the annual meeting of the American Association of Diabetes Educators.

A major review of 84 published articles pertaining to diabetes self-management training found that, overall, evidence supports the efficacy of such training for patients with type 2 diabetes, particularly in the short term.

The authors concluded that further research is needed to assess the effects of self-management interventions on sustained glycemic control; cardiovascular disease risk factors; and, ultimately, microvascular disease and quality of life (Diabetes Care 2001;24:561–87).

The literature is inadequate in many areas, including details about the interventions, assessment of patient satisfaction, the influence of family on patient outcomes, and the particular impact of diabetes self-management interventions on men.

Nearly all the published studies are comprised mostly of female patients, noted Dr. Jack, team leader of Applied Behavioral Research, Epidemiology, Surveillance, and Evaluation at the Centers for Disease Control and Prevention's division of diabetes translation, Atlanta.

Despite the gaps, the literature does support the following counseling strategies for all patients with diabetes:

▸ Frame the teaching to match the patient's perceptions. Simply by asking the question “When you think of diabetes, what do you think of?” can elicit the information needed to focus the teaching based on the patient's perceptions or misperceptions, he said.

▸ Fully inform patients of the purpose and expected effects of interventions—and when to expect these effects. This helps avoid discouragement when results are not immediate. If potential setbacks are likely, warn the patient of this and offer suggestions on what to do.

▸ Suggest small lifestyle changes rather than large ones. Patients can be asked to do just slightly more than they're doing now, such as adding 5 more minutes of walking if they're already doing 10. Many studies on self-efficacy suggest that enhancing a patient's faith in his or her capabilities improves the chances of success.

▸ Be specific. Tell the patient exactly how much to exercise, how often to eat, how intensely to work out, and explain the rationale for the recommendation. Demonstrate your instructions if possible, and write them down on a prescription sheet.

▸ Remember that it's easier to add new behaviors than to eliminate old ones. If weight loss is a goal, it may be more effective to suggest that they begin taking short walks or other light physical activity than to change their current eating patterns. In all studies, dietary habits are harder to change than anything else, Dr. Jack noted.

▸ Link new behaviors to old ones. Suggest that a patient exercise before eating lunch, or use an exercise bike while watching the evening news, or take his or her medication when brushing teeth. Family routine is important too—make sure that what you're telling the patient doesn't interfere with established family activities.

▸ Use the power of the profession. Don't be afraid to tell a patient outright to stop smoking, cut the fat out of the diet, get out of the house more often, or seek additional help.

▸ Get explicit commitments from patients. Ask patients to describe how they plan to follow the intended regimen. Ask them, “What specifically do you plan to do this upcoming week?” If the patient expresses uncertainty, try to brainstorm with him or her about the scenario and alternatives, Dr. Jack said.

▸ Use a combination of strategies. Individual counseling, group psychoeducation, written materials, and community resources will each work for some patients some of the time. Combining them improves the chances for success, he said.

▸ Involve your office staff. A multifaceted team approach, including a nurse, certified diabetes educator, dietitian/nutritionist, and others, is optimal for managing patients with diabetes.

▸ Refer patients with complex problems. Those with severe depression, psychosis, or suicidal ideation need expert help, as do those with less severe but still complicated problems such as difficulty with interpersonal relationships.

SAN DIEGO — Before referring diabetic patients to a dietician, you might want to ask them how they feel about going.

If the findings of a study from the Mayo Clinic are any indication, about a third of patients feel conflicted about it and might not be willing to go without further encouragement. Such patients will often make an appointment but then cancel or simply not show up, Kathleen Krause, R.D., told FAMILY PRACTICE NEWS in an interview at the annual scientific sessions of the American Diabetes Association.

“We wanted to identify the people who won't go so we can try and engage them,” said Ms. Krause, who presented her findings in a poster at the meeting along with her colleague, Steven A. Smith, M.D., of the Division of Endocrinology, Metabolism, and Internal Medicine at the Mayo Clinic, Rochester, Minn.

Of a total 668 primary care patients with diabetes who were mailed a validated survey about choosing to see a dietician, 37% responded.

In those 247 respondents, the mean age was 66 years (range 28–92), 47% were male, and mean diabetes duration was 5 years.

Nearly half (46%) were on oral hypoglycemic agents, 21% on insulin alone, 18% on a combination of the two, and 17% on diet alone.

Overall, 32% of the respondents expressed some degree of conflict about seeing a dietician, based on the proportion who either disagreed or were neutral in response to statements such as “I would meet with a dietician if my health care provider felt it was important” (16%) and “The decision to meet with a dietician is easy for me to make” (31%).

Conflicted patients were just as likely to have been referred to a dietician as were nonconflicted patients, but were less likely to agree to see one.

For the group as a whole, among the most common reasons for not choosing to meet with a dietician were “I already know what to do” (32%), “I have not been successful in the past” (22%), “cost” (18%), and “I will be given an unrealistic diet” (18%).

Other reasons endorsed by more than 10% of the respondents included “Too much conflicting information about diet,” and “I feel overwhelmed.”

Of the 224 respondents who had seen a dietician previously, 76% felt that the dietician had been helpful in his/her approach and 73% said they had made improvements in their diet based on the information they received from the dietician. Among respondents who were conflicted about seeing a dietician, the positive responses were endorsed by just 66% and 51%, respectively, compared with 81% and 84% of respondents who were not conflicted, said Ms. Krause, Dr. Smith, and their associates.

Family and friends appear to play a role in the patient's decision as well.

Although 90% of the nonconflicted group said that their family and friends would support their diet efforts if they saw a dietician, just 79% of those who were conflicted about seeing a dietician said that their friends and family would support them.

But not all the findings of the survey were negative. Three-fourths of all the respondents said that they would like to meet with a dietician to “improve my health,” 65% to “lose weight,” and 62% to “eat nutritiously.”

And, Dr. Smith said, “They don't want to see the dietician, but they still ask me all kinds of nutrition questions.”

SAN DIEGO — Before referring diabetic patients to a dietician, you might want to ask them how they feel about going.

If the findings of a study from the Mayo Clinic are any indication, about a third of patients feel conflicted about it and might not be willing to go without further encouragement. Such patients will often make an appointment but then cancel or simply not show up, Kathleen Krause, R.D., told FAMILY PRACTICE NEWS in an interview at the annual scientific sessions of the American Diabetes Association.

“We wanted to identify the people who won't go so we can try and engage them,” said Ms. Krause, who presented her findings in a poster at the meeting along with her colleague, Steven A. Smith, M.D., of the Division of Endocrinology, Metabolism, and Internal Medicine at the Mayo Clinic, Rochester, Minn.

Of a total 668 primary care patients with diabetes who were mailed a validated survey about choosing to see a dietician, 37% responded.

In those 247 respondents, the mean age was 66 years (range 28–92), 47% were male, and mean diabetes duration was 5 years.

Nearly half (46%) were on oral hypoglycemic agents, 21% on insulin alone, 18% on a combination of the two, and 17% on diet alone.

Overall, 32% of the respondents expressed some degree of conflict about seeing a dietician, based on the proportion who either disagreed or were neutral in response to statements such as “I would meet with a dietician if my health care provider felt it was important” (16%) and “The decision to meet with a dietician is easy for me to make” (31%).

Conflicted patients were just as likely to have been referred to a dietician as were nonconflicted patients, but were less likely to agree to see one.

For the group as a whole, among the most common reasons for not choosing to meet with a dietician were “I already know what to do” (32%), “I have not been successful in the past” (22%), “cost” (18%), and “I will be given an unrealistic diet” (18%).

Other reasons endorsed by more than 10% of the respondents included “Too much conflicting information about diet,” and “I feel overwhelmed.”

Of the 224 respondents who had seen a dietician previously, 76% felt that the dietician had been helpful in his/her approach and 73% said they had made improvements in their diet based on the information they received from the dietician. Among respondents who were conflicted about seeing a dietician, the positive responses were endorsed by just 66% and 51%, respectively, compared with 81% and 84% of respondents who were not conflicted, said Ms. Krause, Dr. Smith, and their associates.

Family and friends appear to play a role in the patient's decision as well.

Although 90% of the nonconflicted group said that their family and friends would support their diet efforts if they saw a dietician, just 79% of those who were conflicted about seeing a dietician said that their friends and family would support them.

But not all the findings of the survey were negative. Three-fourths of all the respondents said that they would like to meet with a dietician to “improve my health,” 65% to “lose weight,” and 62% to “eat nutritiously.”

And, Dr. Smith said, “They don't want to see the dietician, but they still ask me all kinds of nutrition questions.”

SAN DIEGO — Before referring diabetic patients to a dietician, you might want to ask them how they feel about going.

If the findings of a study from the Mayo Clinic are any indication, about a third of patients feel conflicted about it and might not be willing to go without further encouragement. Such patients will often make an appointment but then cancel or simply not show up, Kathleen Krause, R.D., told FAMILY PRACTICE NEWS in an interview at the annual scientific sessions of the American Diabetes Association.

“We wanted to identify the people who won't go so we can try and engage them,” said Ms. Krause, who presented her findings in a poster at the meeting along with her colleague, Steven A. Smith, M.D., of the Division of Endocrinology, Metabolism, and Internal Medicine at the Mayo Clinic, Rochester, Minn.

Of a total 668 primary care patients with diabetes who were mailed a validated survey about choosing to see a dietician, 37% responded.

In those 247 respondents, the mean age was 66 years (range 28–92), 47% were male, and mean diabetes duration was 5 years.

Nearly half (46%) were on oral hypoglycemic agents, 21% on insulin alone, 18% on a combination of the two, and 17% on diet alone.

Overall, 32% of the respondents expressed some degree of conflict about seeing a dietician, based on the proportion who either disagreed or were neutral in response to statements such as “I would meet with a dietician if my health care provider felt it was important” (16%) and “The decision to meet with a dietician is easy for me to make” (31%).

Conflicted patients were just as likely to have been referred to a dietician as were nonconflicted patients, but were less likely to agree to see one.

For the group as a whole, among the most common reasons for not choosing to meet with a dietician were “I already know what to do” (32%), “I have not been successful in the past” (22%), “cost” (18%), and “I will be given an unrealistic diet” (18%).

Other reasons endorsed by more than 10% of the respondents included “Too much conflicting information about diet,” and “I feel overwhelmed.”

Of the 224 respondents who had seen a dietician previously, 76% felt that the dietician had been helpful in his/her approach and 73% said they had made improvements in their diet based on the information they received from the dietician. Among respondents who were conflicted about seeing a dietician, the positive responses were endorsed by just 66% and 51%, respectively, compared with 81% and 84% of respondents who were not conflicted, said Ms. Krause, Dr. Smith, and their associates.

Family and friends appear to play a role in the patient's decision as well.

Although 90% of the nonconflicted group said that their family and friends would support their diet efforts if they saw a dietician, just 79% of those who were conflicted about seeing a dietician said that their friends and family would support them.

But not all the findings of the survey were negative. Three-fourths of all the respondents said that they would like to meet with a dietician to “improve my health,” 65% to “lose weight,” and 62% to “eat nutritiously.”

And, Dr. Smith said, “They don't want to see the dietician, but they still ask me all kinds of nutrition questions.”

Once considered an unusual cause of pediatric infection, Kingella kingae has emerged as potentially the No. 1 cause of septic arthritis in the child younger than 24 months of age, according to Mary Anne Jackson, M.D., chief of pediatric infectious diseases at Children's Mercy Hospital, Kansas City, and professor of pediatrics at the University of Missouri-Kansas City.

This fastidious organism, which is often resistant to clindamycin, colonizes the oropharynx of approximately 15% of healthy toddler children. The problem is, it is difficult to grow on culture, requiring an enhanced isolation methodology and a little longer than normal (4.4 days) to grow. Knowing when to think about K. kingae as a potential pathogen should help guide treatment decision making.

The typical case involves a previously healthy and fully immunized toddler with a recent upper respiratory infection (URI) who presents with a high spiking fever and irritability. The next day, the child is limping.

What tip-offs might suggest that K. kingae should be considered as a potential pathogen, and how might this impact therapeutic decision making?

For the most part, this organism is an important cause of skeletal infection only in those less than 2 years of age. Other information that may be helpful includes the fact that concomitant URI or stomatitis occurs frequently in such patients (over half in one study), suggesting a respiratory or buccal source for the infection. And this organism has a predilection for ankle involvement in cases of arthritis and calcaneal involvement in bone infection.

Since K. kingae is extremely hard to grow on culture, request that the orthopedic surgeon place some of the purulent fluid into a blood culture bottle, in addition to plating for routine culture, Dr. Jackson recommended. Over a decade ago, physicians were alerted to the importance of using BACTEC blood culture bottles to isolate K. kingae in toddlers with skeletal infection (J. Clin. Microbiol. 1992;30:1278–81).

In that study, the investigators analyzed culture records for the period 1988–1991 and compared the performance of routine culture versus use of blood culture bottle for the recovery of pathogens. A diagnostic joint tap was performed in 216 children. Of those, 63 specimens grew significant organisms. Both methods were comparable for recovery of usual pathogens, but K. kingae isolates were detected by the BACTEC system only, in 13 of 14 specimens.

Just how often K. kingae is the culprit in infant septic arthritis is not completely clear since many centers have not routinely used the above technique to enhance growth, she added.

In a study conducted in Atlanta between 1990 and 1995, where joint aspirates were inoculated into thioglycolate broth, rather than blood culture, gram-positive bacteria were identified in 47 of 60 children (78%) younger than 3 years of age with culture-positive hematogenous septic arthritis and acute or subacute osteomyelitis, while gram-negative organisms were identified in 13 (22%).

Of those, K. kingae was cultured in 10 (17%); all of these cases occurred in children between the ages of 10.5 and 23.5 months. (J. Pediatr. Orthop. 1998;18:262–7).

More recent evidence implicates K. kingae in a cluster of skeletal infection in one day care center in Minnesota. Three cases occurred among children aged 17–21 months attending the same toddler classroom. Within the same week, all affected children had onset of fever, and antalgic gait. They all had preceding or concurrent upper respiratory illness. K. kingae was isolated from clinical specimens.

A colonization study was performed in response to the Minnesota outbreak. The investigators demonstrated that 13% of children at the index day care center (and 45% in the room where the cluster occurred) were colonized in the nasopharynx with K. kingae.

Interestingly, no day care center staff or children less than 16 months old were colonized. They compared the nasopharyngeal colonization results with a control day care center. Similarly, 16% of toddler age children were colonized (Pediatrics 2005;116:e206–13).

As the importance of recognizing K. kingae as a pathogen in the infant with skeletal infection is increasingly appreciated, clinical decision making in cases of pediatric skeletal infection is becoming more complex. Dr. Jackson suggested taking a collaborative approach with an infectious disease specialist and an orthopedic surgeon in order to focus on early diagnosis, pathogen isolation, prompt surgical drainage, and appropriate antimicrobial therapy.

Kingella kingae, shown in this Gram stain, is often resistant to clindamycin and is extremely hard to grow on culture. Courtesy Dr. Pablo Yagupsky

Once considered an unusual cause of pediatric infection, Kingella kingae has emerged as potentially the No. 1 cause of septic arthritis in the child younger than 24 months of age, according to Mary Anne Jackson, M.D., chief of pediatric infectious diseases at Children's Mercy Hospital, Kansas City, and professor of pediatrics at the University of Missouri-Kansas City.

This fastidious organism, which is often resistant to clindamycin, colonizes the oropharynx of approximately 15% of healthy toddler children. The problem is, it is difficult to grow on culture, requiring an enhanced isolation methodology and a little longer than normal (4.4 days) to grow. Knowing when to think about K. kingae as a potential pathogen should help guide treatment decision making.

The typical case involves a previously healthy and fully immunized toddler with a recent upper respiratory infection (URI) who presents with a high spiking fever and irritability. The next day, the child is limping.

What tip-offs might suggest that K. kingae should be considered as a potential pathogen, and how might this impact therapeutic decision making?

For the most part, this organism is an important cause of skeletal infection only in those less than 2 years of age. Other information that may be helpful includes the fact that concomitant URI or stomatitis occurs frequently in such patients (over half in one study), suggesting a respiratory or buccal source for the infection. And this organism has a predilection for ankle involvement in cases of arthritis and calcaneal involvement in bone infection.

Since K. kingae is extremely hard to grow on culture, request that the orthopedic surgeon place some of the purulent fluid into a blood culture bottle, in addition to plating for routine culture, Dr. Jackson recommended. Over a decade ago, physicians were alerted to the importance of using BACTEC blood culture bottles to isolate K. kingae in toddlers with skeletal infection (J. Clin. Microbiol. 1992;30:1278–81).

In that study, the investigators analyzed culture records for the period 1988–1991 and compared the performance of routine culture versus use of blood culture bottle for the recovery of pathogens. A diagnostic joint tap was performed in 216 children. Of those, 63 specimens grew significant organisms. Both methods were comparable for recovery of usual pathogens, but K. kingae isolates were detected by the BACTEC system only, in 13 of 14 specimens.

Just how often K. kingae is the culprit in infant septic arthritis is not completely clear since many centers have not routinely used the above technique to enhance growth, she added.

In a study conducted in Atlanta between 1990 and 1995, where joint aspirates were inoculated into thioglycolate broth, rather than blood culture, gram-positive bacteria were identified in 47 of 60 children (78%) younger than 3 years of age with culture-positive hematogenous septic arthritis and acute or subacute osteomyelitis, while gram-negative organisms were identified in 13 (22%).

Of those, K. kingae was cultured in 10 (17%); all of these cases occurred in children between the ages of 10.5 and 23.5 months. (J. Pediatr. Orthop. 1998;18:262–7).

More recent evidence implicates K. kingae in a cluster of skeletal infection in one day care center in Minnesota. Three cases occurred among children aged 17–21 months attending the same toddler classroom. Within the same week, all affected children had onset of fever, and antalgic gait. They all had preceding or concurrent upper respiratory illness. K. kingae was isolated from clinical specimens.

A colonization study was performed in response to the Minnesota outbreak. The investigators demonstrated that 13% of children at the index day care center (and 45% in the room where the cluster occurred) were colonized in the nasopharynx with K. kingae.

Interestingly, no day care center staff or children less than 16 months old were colonized. They compared the nasopharyngeal colonization results with a control day care center. Similarly, 16% of toddler age children were colonized (Pediatrics 2005;116:e206–13).

As the importance of recognizing K. kingae as a pathogen in the infant with skeletal infection is increasingly appreciated, clinical decision making in cases of pediatric skeletal infection is becoming more complex. Dr. Jackson suggested taking a collaborative approach with an infectious disease specialist and an orthopedic surgeon in order to focus on early diagnosis, pathogen isolation, prompt surgical drainage, and appropriate antimicrobial therapy.

Kingella kingae, shown in this Gram stain, is often resistant to clindamycin and is extremely hard to grow on culture. Courtesy Dr. Pablo Yagupsky

Once considered an unusual cause of pediatric infection, Kingella kingae has emerged as potentially the No. 1 cause of septic arthritis in the child younger than 24 months of age, according to Mary Anne Jackson, M.D., chief of pediatric infectious diseases at Children's Mercy Hospital, Kansas City, and professor of pediatrics at the University of Missouri-Kansas City.

This fastidious organism, which is often resistant to clindamycin, colonizes the oropharynx of approximately 15% of healthy toddler children. The problem is, it is difficult to grow on culture, requiring an enhanced isolation methodology and a little longer than normal (4.4 days) to grow. Knowing when to think about K. kingae as a potential pathogen should help guide treatment decision making.

The typical case involves a previously healthy and fully immunized toddler with a recent upper respiratory infection (URI) who presents with a high spiking fever and irritability. The next day, the child is limping.

What tip-offs might suggest that K. kingae should be considered as a potential pathogen, and how might this impact therapeutic decision making?

For the most part, this organism is an important cause of skeletal infection only in those less than 2 years of age. Other information that may be helpful includes the fact that concomitant URI or stomatitis occurs frequently in such patients (over half in one study), suggesting a respiratory or buccal source for the infection. And this organism has a predilection for ankle involvement in cases of arthritis and calcaneal involvement in bone infection.

Since K. kingae is extremely hard to grow on culture, request that the orthopedic surgeon place some of the purulent fluid into a blood culture bottle, in addition to plating for routine culture, Dr. Jackson recommended. Over a decade ago, physicians were alerted to the importance of using BACTEC blood culture bottles to isolate K. kingae in toddlers with skeletal infection (J. Clin. Microbiol. 1992;30:1278–81).

In that study, the investigators analyzed culture records for the period 1988–1991 and compared the performance of routine culture versus use of blood culture bottle for the recovery of pathogens. A diagnostic joint tap was performed in 216 children. Of those, 63 specimens grew significant organisms. Both methods were comparable for recovery of usual pathogens, but K. kingae isolates were detected by the BACTEC system only, in 13 of 14 specimens.

Just how often K. kingae is the culprit in infant septic arthritis is not completely clear since many centers have not routinely used the above technique to enhance growth, she added.

In a study conducted in Atlanta between 1990 and 1995, where joint aspirates were inoculated into thioglycolate broth, rather than blood culture, gram-positive bacteria were identified in 47 of 60 children (78%) younger than 3 years of age with culture-positive hematogenous septic arthritis and acute or subacute osteomyelitis, while gram-negative organisms were identified in 13 (22%).

Of those, K. kingae was cultured in 10 (17%); all of these cases occurred in children between the ages of 10.5 and 23.5 months. (J. Pediatr. Orthop. 1998;18:262–7).

More recent evidence implicates K. kingae in a cluster of skeletal infection in one day care center in Minnesota. Three cases occurred among children aged 17–21 months attending the same toddler classroom. Within the same week, all affected children had onset of fever, and antalgic gait. They all had preceding or concurrent upper respiratory illness. K. kingae was isolated from clinical specimens.

A colonization study was performed in response to the Minnesota outbreak. The investigators demonstrated that 13% of children at the index day care center (and 45% in the room where the cluster occurred) were colonized in the nasopharynx with K. kingae.

Interestingly, no day care center staff or children less than 16 months old were colonized. They compared the nasopharyngeal colonization results with a control day care center. Similarly, 16% of toddler age children were colonized (Pediatrics 2005;116:e206–13).

As the importance of recognizing K. kingae as a pathogen in the infant with skeletal infection is increasingly appreciated, clinical decision making in cases of pediatric skeletal infection is becoming more complex. Dr. Jackson suggested taking a collaborative approach with an infectious disease specialist and an orthopedic surgeon in order to focus on early diagnosis, pathogen isolation, prompt surgical drainage, and appropriate antimicrobial therapy.

Kingella kingae, shown in this Gram stain, is often resistant to clindamycin and is extremely hard to grow on culture. Courtesy Dr. Pablo Yagupsky