Robert Finn

SAN FRANCISCO — A new, large study has concluded that the Rochester criteria—for determining which febrile infants are at low risk of having a serious bacterial infection—are not as sensitive as once thought.

But with a modification that adds information about the infant's age and viral status, the sensitivity and negative predictive value of the Rochester criteria can be maintained, Dr. Carrie L. Byington said at the annual meeting of the Pediatric Academic Societies.

The prospective cohort study involved 1,779 febrile infants 1–90 days of age. Dr. Byington and her colleagues from the University of Utah, Salt Lake City, analyzed these cases according to the original Rochester criteria, and also evaluated several possible modifications of the criteria.

Developed from data collected in the 1970s and 1980s from 233 infants, the 15 Rochester criteria are based on patient history, physical examination, and laboratory values. Infants with no positive criteria are said to have only a 1.4% risk of serious bacterial infection, while infants with one or more positive criteria are considered to be at high risk, having a 21% chance of serious bacterial infection.

But the Rochester criteria can be unwieldy, and Dr. Byington noted that many physicians routinely make decisions based on factors that are not part of the criteria, such as the patient's age and viral status.

In the original studies, the Rochester criteria were said to have a sensitivity of 95.7% and a negative predictive value of 99.3%. But in this series of infants seen in Salt Lake City, the Rochester criteria yielded a sensitivity of 90% and a negative predictive value of 97%. By the original criteria, 33% of the infants were said to have a low risk of serious bacterial infection, and 67% were said to have a high risk. As it turned out, only 10% of the infants, whose average age was 31 days, had a serious bacterial infection.

The investigators determined that four of the criteria were significantly associated with serious bacterial illness. They were:

▸ A urinalysis with more than 10 white blood cells per high-power field (odds ratio 38.8).

▸ An absolute band count greater than 1,500 (odds ratio 2.7).

▸ A white blood cell count of less than 5,000 or greater than 15,000 per mm

▸ The combination of chronic illness and prematurity (odds ratio 9.7). The investigators defined chronic illness as any major anatomic abnormality or major immune deficiency, and they defined prematurity as a gestational age of 37 weeks or less.

Together they refer to these four criteria as the “Modified Rochester Criteria” (MRC).

In addition, high-risk infants (by MRC) aged 29–90 days had a 42% smaller chance of having a serious bacterial infection than high-risk infants between 1–28 days old. And infants with a confirmed viral illness were 70% less likely to have a serious bacterial infection than those with no confirmed viral illness.

When age and viral illness are added to the MRC, the sensitivity rises to 96%, while the negative predictive value remains at 97%.

In fact, this combination of factors can be used to stratify patients into low-, medium-, and high-risk categories. Patients who are negative for the MRC and positive for virus are at low risk, having only a 0.7% chance of serious bacterial infection if they are 29 days or older, and a 1.7% risk if they are younger.

Patients who have at least one positive MRC finding and who are positive for virus form the medium-risk group. The older infants have a 3.8% chance of having a serious bacterial infection, while the younger ones have a 6.5% chance.

Patients who are MRC positive and negative for virus are at the highest risk. The older infants have a 22% chance of having a serious bacterial infection, and the younger infants have a 33% chance.

“We believe that the diagnosis of viral infections should be a standard component of a rule-out-sepsis evaluation,” she said.

In response to a question from the audience, Dr. Byington agreed that even a 1% chance of serious bacterial infection merits consideration. She said that her goal is not to identify a group of infants that can be safely left untreated, but rather to decrease the length of time it takes to do a full sepsis evaluation from 53–72 hours to 24 hours.

“My take-home message is not to stop looking for bacteria, but to speed up the way we can make that decision,” she said. “I am working toward developing diagnostic technology that can diagnose both bacterial and viral pathogens—15 pathogens [in] 15 minutes.”

SAN FRANCISCO — A new, large study has concluded that the Rochester criteria—for determining which febrile infants are at low risk of having a serious bacterial infection—are not as sensitive as once thought.

But with a modification that adds information about the infant's age and viral status, the sensitivity and negative predictive value of the Rochester criteria can be maintained, Dr. Carrie L. Byington said at the annual meeting of the Pediatric Academic Societies.

The prospective cohort study involved 1,779 febrile infants 1–90 days of age. Dr. Byington and her colleagues from the University of Utah, Salt Lake City, analyzed these cases according to the original Rochester criteria, and also evaluated several possible modifications of the criteria.

Developed from data collected in the 1970s and 1980s from 233 infants, the 15 Rochester criteria are based on patient history, physical examination, and laboratory values. Infants with no positive criteria are said to have only a 1.4% risk of serious bacterial infection, while infants with one or more positive criteria are considered to be at high risk, having a 21% chance of serious bacterial infection.

But the Rochester criteria can be unwieldy, and Dr. Byington noted that many physicians routinely make decisions based on factors that are not part of the criteria, such as the patient's age and viral status.

In the original studies, the Rochester criteria were said to have a sensitivity of 95.7% and a negative predictive value of 99.3%. But in this series of infants seen in Salt Lake City, the Rochester criteria yielded a sensitivity of 90% and a negative predictive value of 97%. By the original criteria, 33% of the infants were said to have a low risk of serious bacterial infection, and 67% were said to have a high risk. As it turned out, only 10% of the infants, whose average age was 31 days, had a serious bacterial infection.

The investigators determined that four of the criteria were significantly associated with serious bacterial illness. They were:

▸ A urinalysis with more than 10 white blood cells per high-power field (odds ratio 38.8).

▸ An absolute band count greater than 1,500 (odds ratio 2.7).

▸ A white blood cell count of less than 5,000 or greater than 15,000 per mm

▸ The combination of chronic illness and prematurity (odds ratio 9.7). The investigators defined chronic illness as any major anatomic abnormality or major immune deficiency, and they defined prematurity as a gestational age of 37 weeks or less.

Together they refer to these four criteria as the “Modified Rochester Criteria” (MRC).

In addition, high-risk infants (by MRC) aged 29–90 days had a 42% smaller chance of having a serious bacterial infection than high-risk infants between 1–28 days old. And infants with a confirmed viral illness were 70% less likely to have a serious bacterial infection than those with no confirmed viral illness.

When age and viral illness are added to the MRC, the sensitivity rises to 96%, while the negative predictive value remains at 97%.

In fact, this combination of factors can be used to stratify patients into low-, medium-, and high-risk categories. Patients who are negative for the MRC and positive for virus are at low risk, having only a 0.7% chance of serious bacterial infection if they are 29 days or older, and a 1.7% risk if they are younger.

Patients who have at least one positive MRC finding and who are positive for virus form the medium-risk group. The older infants have a 3.8% chance of having a serious bacterial infection, while the younger ones have a 6.5% chance.

Patients who are MRC positive and negative for virus are at the highest risk. The older infants have a 22% chance of having a serious bacterial infection, and the younger infants have a 33% chance.

“We believe that the diagnosis of viral infections should be a standard component of a rule-out-sepsis evaluation,” she said.

In response to a question from the audience, Dr. Byington agreed that even a 1% chance of serious bacterial infection merits consideration. She said that her goal is not to identify a group of infants that can be safely left untreated, but rather to decrease the length of time it takes to do a full sepsis evaluation from 53–72 hours to 24 hours.

“My take-home message is not to stop looking for bacteria, but to speed up the way we can make that decision,” she said. “I am working toward developing diagnostic technology that can diagnose both bacterial and viral pathogens—15 pathogens [in] 15 minutes.”

SAN FRANCISCO — A new, large study has concluded that the Rochester criteria—for determining which febrile infants are at low risk of having a serious bacterial infection—are not as sensitive as once thought.

But with a modification that adds information about the infant's age and viral status, the sensitivity and negative predictive value of the Rochester criteria can be maintained, Dr. Carrie L. Byington said at the annual meeting of the Pediatric Academic Societies.

The prospective cohort study involved 1,779 febrile infants 1–90 days of age. Dr. Byington and her colleagues from the University of Utah, Salt Lake City, analyzed these cases according to the original Rochester criteria, and also evaluated several possible modifications of the criteria.

Developed from data collected in the 1970s and 1980s from 233 infants, the 15 Rochester criteria are based on patient history, physical examination, and laboratory values. Infants with no positive criteria are said to have only a 1.4% risk of serious bacterial infection, while infants with one or more positive criteria are considered to be at high risk, having a 21% chance of serious bacterial infection.

But the Rochester criteria can be unwieldy, and Dr. Byington noted that many physicians routinely make decisions based on factors that are not part of the criteria, such as the patient's age and viral status.

In the original studies, the Rochester criteria were said to have a sensitivity of 95.7% and a negative predictive value of 99.3%. But in this series of infants seen in Salt Lake City, the Rochester criteria yielded a sensitivity of 90% and a negative predictive value of 97%. By the original criteria, 33% of the infants were said to have a low risk of serious bacterial infection, and 67% were said to have a high risk. As it turned out, only 10% of the infants, whose average age was 31 days, had a serious bacterial infection.

The investigators determined that four of the criteria were significantly associated with serious bacterial illness. They were:

▸ A urinalysis with more than 10 white blood cells per high-power field (odds ratio 38.8).

▸ An absolute band count greater than 1,500 (odds ratio 2.7).

▸ A white blood cell count of less than 5,000 or greater than 15,000 per mm

▸ The combination of chronic illness and prematurity (odds ratio 9.7). The investigators defined chronic illness as any major anatomic abnormality or major immune deficiency, and they defined prematurity as a gestational age of 37 weeks or less.

Together they refer to these four criteria as the “Modified Rochester Criteria” (MRC).

In addition, high-risk infants (by MRC) aged 29–90 days had a 42% smaller chance of having a serious bacterial infection than high-risk infants between 1–28 days old. And infants with a confirmed viral illness were 70% less likely to have a serious bacterial infection than those with no confirmed viral illness.

When age and viral illness are added to the MRC, the sensitivity rises to 96%, while the negative predictive value remains at 97%.

In fact, this combination of factors can be used to stratify patients into low-, medium-, and high-risk categories. Patients who are negative for the MRC and positive for virus are at low risk, having only a 0.7% chance of serious bacterial infection if they are 29 days or older, and a 1.7% risk if they are younger.

Patients who have at least one positive MRC finding and who are positive for virus form the medium-risk group. The older infants have a 3.8% chance of having a serious bacterial infection, while the younger ones have a 6.5% chance.

Patients who are MRC positive and negative for virus are at the highest risk. The older infants have a 22% chance of having a serious bacterial infection, and the younger infants have a 33% chance.

“We believe that the diagnosis of viral infections should be a standard component of a rule-out-sepsis evaluation,” she said.

In response to a question from the audience, Dr. Byington agreed that even a 1% chance of serious bacterial infection merits consideration. She said that her goal is not to identify a group of infants that can be safely left untreated, but rather to decrease the length of time it takes to do a full sepsis evaluation from 53–72 hours to 24 hours.

“My take-home message is not to stop looking for bacteria, but to speed up the way we can make that decision,” she said. “I am working toward developing diagnostic technology that can diagnose both bacterial and viral pathogens—15 pathogens [in] 15 minutes.”

SAN FRANCISCO — The rapid diagnostic test kit for influenza significantly improves the management of infants and young children who are presenting to the emergency department with fever of unknown origin, according to a poster presentation by Dr. Javier Benito-Fernández at the annual meeting of the Pediatric Academic Societies.

Among 206 children aged 0–36 months, those who tested positive on the rapid diagnostic test underwent fewer laboratory tests and fewer radiographs, had a shorter length of stay in the emergency department, were less likely to be admitted to the hospital, and were much less likely to be treated with antibiotics.

The prospective study was conducted during the influenza seasons of 2003–2004 and 2004–2005 at Hospital Cruces, University of the Basque Country, Baracaldo, Vizcaya, Spain. All infants less than 3 months old with a fever of unknown origin received a rapid diagnostic test, the Directigen Flu A+B test.

Infants and children 3–36 months of age received the test only if their temperature was over 39° C and the pediatrician thought that laboratory tests were necessary to rule out a bacterial infection. Of the 206 children, 84 tested positive and 122 tested negative on the rapid diagnostic test.

There were no significant differences between the positive and negative groups in mean age (about 6.75 months), mean temperature (about 39.3° C), and several demographic factors.

Children who tested positive were significantly less likely to undergo urinalysis (81% vs. 100%), blood tests (33% vs. 100%), chest x-rays (14% vs. 32%), and lumbar puncture (2% vs. 21%).

None of the children who tested positive received antibiotics, compared with 39% of the children who tested negative.

Children who tested positive also spent significantly less time in the emergency department, an average of 214 minutes versus 470 minutes for those testing negative.

Moreover, those testing positive were less likely to be admitted to hospital (2% vs. 21%).

There was no significant difference, however, in the rate of children returning to the emergency department for additional medical care: 11.9% of the children testing positive versus 11.5% of those testing negative.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — The rapid diagnostic test kit for influenza significantly improves the management of infants and young children who are presenting to the emergency department with fever of unknown origin, according to a poster presentation by Dr. Javier Benito-Fernández at the annual meeting of the Pediatric Academic Societies.

Among 206 children aged 0–36 months, those who tested positive on the rapid diagnostic test underwent fewer laboratory tests and fewer radiographs, had a shorter length of stay in the emergency department, were less likely to be admitted to the hospital, and were much less likely to be treated with antibiotics.

The prospective study was conducted during the influenza seasons of 2003–2004 and 2004–2005 at Hospital Cruces, University of the Basque Country, Baracaldo, Vizcaya, Spain. All infants less than 3 months old with a fever of unknown origin received a rapid diagnostic test, the Directigen Flu A+B test.

Infants and children 3–36 months of age received the test only if their temperature was over 39° C and the pediatrician thought that laboratory tests were necessary to rule out a bacterial infection. Of the 206 children, 84 tested positive and 122 tested negative on the rapid diagnostic test.

There were no significant differences between the positive and negative groups in mean age (about 6.75 months), mean temperature (about 39.3° C), and several demographic factors.

Children who tested positive were significantly less likely to undergo urinalysis (81% vs. 100%), blood tests (33% vs. 100%), chest x-rays (14% vs. 32%), and lumbar puncture (2% vs. 21%).

None of the children who tested positive received antibiotics, compared with 39% of the children who tested negative.

Children who tested positive also spent significantly less time in the emergency department, an average of 214 minutes versus 470 minutes for those testing negative.

Moreover, those testing positive were less likely to be admitted to hospital (2% vs. 21%).

There was no significant difference, however, in the rate of children returning to the emergency department for additional medical care: 11.9% of the children testing positive versus 11.5% of those testing negative.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — The rapid diagnostic test kit for influenza significantly improves the management of infants and young children who are presenting to the emergency department with fever of unknown origin, according to a poster presentation by Dr. Javier Benito-Fernández at the annual meeting of the Pediatric Academic Societies.

Among 206 children aged 0–36 months, those who tested positive on the rapid diagnostic test underwent fewer laboratory tests and fewer radiographs, had a shorter length of stay in the emergency department, were less likely to be admitted to the hospital, and were much less likely to be treated with antibiotics.

The prospective study was conducted during the influenza seasons of 2003–2004 and 2004–2005 at Hospital Cruces, University of the Basque Country, Baracaldo, Vizcaya, Spain. All infants less than 3 months old with a fever of unknown origin received a rapid diagnostic test, the Directigen Flu A+B test.

Infants and children 3–36 months of age received the test only if their temperature was over 39° C and the pediatrician thought that laboratory tests were necessary to rule out a bacterial infection. Of the 206 children, 84 tested positive and 122 tested negative on the rapid diagnostic test.

There were no significant differences between the positive and negative groups in mean age (about 6.75 months), mean temperature (about 39.3° C), and several demographic factors.

Children who tested positive were significantly less likely to undergo urinalysis (81% vs. 100%), blood tests (33% vs. 100%), chest x-rays (14% vs. 32%), and lumbar puncture (2% vs. 21%).

None of the children who tested positive received antibiotics, compared with 39% of the children who tested negative.

Children who tested positive also spent significantly less time in the emergency department, an average of 214 minutes versus 470 minutes for those testing negative.

Moreover, those testing positive were less likely to be admitted to hospital (2% vs. 21%).

There was no significant difference, however, in the rate of children returning to the emergency department for additional medical care: 11.9% of the children testing positive versus 11.5% of those testing negative.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

DENVER — Shoulder dislocations are common occurrences, but there's surprisingly little agreement on the best way to treat them, Dr. John E. Kuhn said at the annual meeting of the American College of Sports Medicine.

Based on the level of supporting evidence, Dr. Kuhn of Vanderbilt University, Nashville, Tenn., divided knowledge about shoulder dislocations into the following three categories:

▸ Things we know. Three well-designed, randomized, controlled trials have looked at premedication using IV sedation compared with intraarticular injections of lidocaine. Taken together, the success rate for reducing shoulder dislocation was identical for the two methods—92%. Likewise, there were no significant differences in the amount of pain the patients experienced. But there were large differences in the complication rates. About 16% of the patients receiving IV sedation experienced a complication, primarily respiratory depression requiring naloxone or some other drug. Only 1% of the patients receiving lidocaine experienced a complication.

In two out of three studies, the time to reduction was about 5 minutes shorter with IV sedation. However, the total time in the emergency department was a full hour shorter for lidocaine in all three studies.

Five studies address whether immobilization helps reduce recurrence rates in first-time dislocators, and if so, whether it is better to immobilize the joint in an external or internal rotation. There is excellent level 1 evidence that immobilization in internal rotation has no effect on recurrence rates, and there's level 2 evidence indicating that immobilization in an external rotation may reduce recurrence rates.

Arthroscopic surgery decreases recurrence in first-time dislocators, compared with those who receive nonoperative treatment, according to the findings from three level 1 studies that were highly significant, both statistically and clinically. But that doesn't mean that all first-time dislocators should have arthroscopic surgery, he cautioned. The recurrence rate is about 50% with nonoperative treatment, but it's difficult to predict who will benefit most from surgery. Dr. Kuhn suggested that younger patients who have a Hill-Sachs deformity, and those who engage in contact or overhead sports, are most likely to benefit.

The recurrence rates were similar regardless of whether open versus arthroscopic surgery techniques were used for Bankart repair in the recurrent dislocator, according to the findings of three good studies. Given the easier postoperative course following arthroscopic repair, Dr. Kuhn suggested that “if you feel you have the skills to do it arthroscopically, you should go ahead and do it arthroscopically.”

▸ Things we think are true. In the course of his literature review, Dr. Kuhn tabulated no fewer than 24 different methods for reducing shoulder dislocations. Most are variations of six basic techniques: the Kocher technique, the Milch technique, the Stimson technique, external rotation, traction/countertraction, and scapula manipulation. Studies comparing these various techniques are rarely well controlled, and they are subject to performance bias. All report about 80%–100% success rates for each of the techniques.

In the absence of rigorous comparison studies, no one technique can be considered better than any other. He suggests that physicians learn at least two or three of the techniques, so that if one doesn't work in a particular patient the physician will have other options.

The Stimson technique, he noted, may be especially well suited for use in a busy office. In this technique, the patient lies face down on an exam table with the affected arm dangling down over the side. Weights are placed on the arm, and the patient is left alone for 15–20 minutes. Within that time the patient's muscles typically relax and the shoulder pops in by itself.

▸ Things we believe. One of the biggest questions related to shoulder dislocation is how soon an athlete can return to his or her sport after the shoulder has been reduced. Two articles in the literature address this question, but are based not on scientific study but on expert opinion, or level 5 evidence. Here, the consensus appears to be that it's safe to return to activity when the patient has little or no pain, regains near-normal range of motion and near-normal strength in the affected arm, and when the patient is able to perform sport-specific activities.

DENVER — Shoulder dislocations are common occurrences, but there's surprisingly little agreement on the best way to treat them, Dr. John E. Kuhn said at the annual meeting of the American College of Sports Medicine.

Based on the level of supporting evidence, Dr. Kuhn of Vanderbilt University, Nashville, Tenn., divided knowledge about shoulder dislocations into the following three categories:

▸ Things we know. Three well-designed, randomized, controlled trials have looked at premedication using IV sedation compared with intraarticular injections of lidocaine. Taken together, the success rate for reducing shoulder dislocation was identical for the two methods—92%. Likewise, there were no significant differences in the amount of pain the patients experienced. But there were large differences in the complication rates. About 16% of the patients receiving IV sedation experienced a complication, primarily respiratory depression requiring naloxone or some other drug. Only 1% of the patients receiving lidocaine experienced a complication.

In two out of three studies, the time to reduction was about 5 minutes shorter with IV sedation. However, the total time in the emergency department was a full hour shorter for lidocaine in all three studies.

Five studies address whether immobilization helps reduce recurrence rates in first-time dislocators, and if so, whether it is better to immobilize the joint in an external or internal rotation. There is excellent level 1 evidence that immobilization in internal rotation has no effect on recurrence rates, and there's level 2 evidence indicating that immobilization in an external rotation may reduce recurrence rates.

Arthroscopic surgery decreases recurrence in first-time dislocators, compared with those who receive nonoperative treatment, according to the findings from three level 1 studies that were highly significant, both statistically and clinically. But that doesn't mean that all first-time dislocators should have arthroscopic surgery, he cautioned. The recurrence rate is about 50% with nonoperative treatment, but it's difficult to predict who will benefit most from surgery. Dr. Kuhn suggested that younger patients who have a Hill-Sachs deformity, and those who engage in contact or overhead sports, are most likely to benefit.

The recurrence rates were similar regardless of whether open versus arthroscopic surgery techniques were used for Bankart repair in the recurrent dislocator, according to the findings of three good studies. Given the easier postoperative course following arthroscopic repair, Dr. Kuhn suggested that “if you feel you have the skills to do it arthroscopically, you should go ahead and do it arthroscopically.”

▸ Things we think are true. In the course of his literature review, Dr. Kuhn tabulated no fewer than 24 different methods for reducing shoulder dislocations. Most are variations of six basic techniques: the Kocher technique, the Milch technique, the Stimson technique, external rotation, traction/countertraction, and scapula manipulation. Studies comparing these various techniques are rarely well controlled, and they are subject to performance bias. All report about 80%–100% success rates for each of the techniques.

In the absence of rigorous comparison studies, no one technique can be considered better than any other. He suggests that physicians learn at least two or three of the techniques, so that if one doesn't work in a particular patient the physician will have other options.

The Stimson technique, he noted, may be especially well suited for use in a busy office. In this technique, the patient lies face down on an exam table with the affected arm dangling down over the side. Weights are placed on the arm, and the patient is left alone for 15–20 minutes. Within that time the patient's muscles typically relax and the shoulder pops in by itself.

▸ Things we believe. One of the biggest questions related to shoulder dislocation is how soon an athlete can return to his or her sport after the shoulder has been reduced. Two articles in the literature address this question, but are based not on scientific study but on expert opinion, or level 5 evidence. Here, the consensus appears to be that it's safe to return to activity when the patient has little or no pain, regains near-normal range of motion and near-normal strength in the affected arm, and when the patient is able to perform sport-specific activities.

DENVER — Shoulder dislocations are common occurrences, but there's surprisingly little agreement on the best way to treat them, Dr. John E. Kuhn said at the annual meeting of the American College of Sports Medicine.

Based on the level of supporting evidence, Dr. Kuhn of Vanderbilt University, Nashville, Tenn., divided knowledge about shoulder dislocations into the following three categories:

▸ Things we know. Three well-designed, randomized, controlled trials have looked at premedication using IV sedation compared with intraarticular injections of lidocaine. Taken together, the success rate for reducing shoulder dislocation was identical for the two methods—92%. Likewise, there were no significant differences in the amount of pain the patients experienced. But there were large differences in the complication rates. About 16% of the patients receiving IV sedation experienced a complication, primarily respiratory depression requiring naloxone or some other drug. Only 1% of the patients receiving lidocaine experienced a complication.

In two out of three studies, the time to reduction was about 5 minutes shorter with IV sedation. However, the total time in the emergency department was a full hour shorter for lidocaine in all three studies.

Five studies address whether immobilization helps reduce recurrence rates in first-time dislocators, and if so, whether it is better to immobilize the joint in an external or internal rotation. There is excellent level 1 evidence that immobilization in internal rotation has no effect on recurrence rates, and there's level 2 evidence indicating that immobilization in an external rotation may reduce recurrence rates.

Arthroscopic surgery decreases recurrence in first-time dislocators, compared with those who receive nonoperative treatment, according to the findings from three level 1 studies that were highly significant, both statistically and clinically. But that doesn't mean that all first-time dislocators should have arthroscopic surgery, he cautioned. The recurrence rate is about 50% with nonoperative treatment, but it's difficult to predict who will benefit most from surgery. Dr. Kuhn suggested that younger patients who have a Hill-Sachs deformity, and those who engage in contact or overhead sports, are most likely to benefit.

The recurrence rates were similar regardless of whether open versus arthroscopic surgery techniques were used for Bankart repair in the recurrent dislocator, according to the findings of three good studies. Given the easier postoperative course following arthroscopic repair, Dr. Kuhn suggested that “if you feel you have the skills to do it arthroscopically, you should go ahead and do it arthroscopically.”

▸ Things we think are true. In the course of his literature review, Dr. Kuhn tabulated no fewer than 24 different methods for reducing shoulder dislocations. Most are variations of six basic techniques: the Kocher technique, the Milch technique, the Stimson technique, external rotation, traction/countertraction, and scapula manipulation. Studies comparing these various techniques are rarely well controlled, and they are subject to performance bias. All report about 80%–100% success rates for each of the techniques.

In the absence of rigorous comparison studies, no one technique can be considered better than any other. He suggests that physicians learn at least two or three of the techniques, so that if one doesn't work in a particular patient the physician will have other options.

The Stimson technique, he noted, may be especially well suited for use in a busy office. In this technique, the patient lies face down on an exam table with the affected arm dangling down over the side. Weights are placed on the arm, and the patient is left alone for 15–20 minutes. Within that time the patient's muscles typically relax and the shoulder pops in by itself.

▸ Things we believe. One of the biggest questions related to shoulder dislocation is how soon an athlete can return to his or her sport after the shoulder has been reduced. Two articles in the literature address this question, but are based not on scientific study but on expert opinion, or level 5 evidence. Here, the consensus appears to be that it's safe to return to activity when the patient has little or no pain, regains near-normal range of motion and near-normal strength in the affected arm, and when the patient is able to perform sport-specific activities.

SAN FRANCISCO — Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 46 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting.

SAN FRANCISCO — Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 46 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting.

SAN FRANCISCO — Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 46 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting.

SAN FRANCISCO — An 18-month-old child who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule was more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than one who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ont., and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months. This diagnosis was based on the clinician's best judgment following a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised.

The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASD) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was in the not ASD range at 24 months and did not have a diagnosis of ASD at 3 years. Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%). The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — An 18-month-old child who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule was more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than one who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ont., and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months. This diagnosis was based on the clinician's best judgment following a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised.

The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASD) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was in the not ASD range at 24 months and did not have a diagnosis of ASD at 3 years. Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%). The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — An 18-month-old child who scored above the threshold for autism spectrum disorders on the Autism Diagnostic Observation Schedule was more than six times as likely to have a clinical diagnosis of autism spectrum disorder at the age of 3 years than one who scored lower, Dr. Lonnie Zwaigenbaum reported in a poster presentation at the annual meeting of the Pediatric Academic Societies.

Nevertheless, scores on the Autism Diagnostic Observation Schedule (ADOS) must be interpreted with caution in children who are 18 months old, wrote Dr. Zwaigenbaum of McMaster University, Hamilton, Ont., and his colleagues. ADOS scores should be interpreted in the context of an overall clinical assessment, because the test has a high sensitivity but a relatively low specificity, missing more than 50% of the children with diagnoses at 3 years.

The study involved 101 children who were at increased risk of autism by virtue of having an older sibling with autism. Also included in the trial were 42 control children with no increased risk of autism.

The children were assessed with ADOS and the MacArthur Communicative Development Inventory at the average age of 18 months, and they received a blinded diagnosis by an expert clinician at an average age of 39 months. This diagnosis was based on the clinician's best judgment following a comprehensive assessment that included the ADOS, the DSM-IV, and the Autism Diagnostic Interview-Revised.

The ADOS scoring algorithm includes one cutoff score for autism spectrum disorders (ASD) and a higher cutoff score for autism. Only one of the control children scored in the ASD range at 18 months, but that child was in the not ASD range at 24 months and did not have a diagnosis of ASD at 3 years. Using the autism cutoff, the 18-month assessment identified 9 of 20 children who ended up with a clinical diagnosis at 3 years (sensitivity of 45%) and 6 of 81 children who did not receive a diagnosis at age 3 (specificity of 93%). The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics. Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs. However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion. Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer. Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion. The conclusion was that antihistamines actually prolong middle air effusion in patients with AOM and thus should not be used. The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;[3]:CD001727).

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics. Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs. However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion. Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer. Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion. The conclusion was that antihistamines actually prolong middle air effusion in patients with AOM and thus should not be used. The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;[3]:CD001727).

SAN FRANCISCO — Although it may seem logical that corticosteroids, antihistamines, and/or decongestants may be good adjunctive treatments of acute otitis media, the evidence does not bear this out, Dr. Tasnee Chonmaitree said at the annual meeting of the Pediatric Academic Societies.

The rationale for using corticosteroids and antihistamines is clear: Drugs that can inhibit the synthesis or counteract the actions of inflammatory mediators should help improve the outcome—or at least provide some symptom relief—in acute otitis media (AOM), said Dr. Chonmaitree of the University of Texas, Galveston.

Corticosteroids, for example, inhibit the recruitment of leukocytes and monocytes to the affected area, reduce vascular permeability, and inhibit the synthesis or release of numerous inflammatory mediators and cytokines. Moreover, there is evidence that corticosteroids improve outcomes in otorrhea in children and AOM in animal models.

But two randomized controlled trials conducted by Dr. Chonmaitree and her colleagues demonstrated no clear benefit for corticosteroids and antihistamines alone or in combination in patients taking antibiotics. Both studies had four arms. Some patients received two placebos, some received one placebo plus corticosteroid, some received one placebo plus antihistamine, and some received corticosteroid plus antihistamine.

The first study involved 80 patients, aged 3 months to 6 years, who were followed for 3 months. There were no differences in laboratory values, including levels of histamine and leukotriene B4 that could be attributed to either of the drugs. However, corticosteroid treatment was associated with a lower rate of treatment failure within the first 2 weeks and a shorter duration of middle ear effusion.

A second trial followed 180 high-risk children with at least two previous episodes of AOM for 6 months. There were no statistically significant differences in the percentage of patients experiencing treatment failure in the first 2 weeks. But there was a significant difference in the duration of middle ear effusion. This difference favored placebo.

Patients receiving placebo alone experienced a median of 25 days of middle ear effusion. Patients receiving antihistamine alone experienced middle ear effusion for a median of 73 days, almost three times longer. Patients taking corticosteroid alone had about the same duration of effusion as did the placebo patients, and patients taking antihistamine and corticosteroid experienced a median of 36 days of effusion. The conclusion was that antihistamines actually prolong middle air effusion in patients with AOM and thus should not be used. The Cochrane Collaboration conducted a detailed metaanalysis on the use of antihistamines and/or decongestants in AOM and came to similar conclusions (Cochrane Database Syst. Rev. 2004;[3]:CD001727).

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004. Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania. At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates reported in U.S. vaccine studies.

Of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004. Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania. At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates reported in U.S. vaccine studies.

Of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — Records for most vaccines from most countries of origin for children adopted internationally are trustworthy, Dr. Bindy Crouch said in a poster presentation at the annual meeting of the Pediatric Academic Societies.

For this reason, Dr. Crouch of the State University of New York at Stony Brook and her colleagues recommend that antibody titers should be tested before revaccinating adopted children who have documentation of vaccines given in their countries of origin.

The study involved a retrospective chart review of 219 internationally adopted children seen between January 2003 and December 2004. Of those children, 72 came from China, 87 from Russia, 28 from Korea, 19 from Guatemala, 4 from Ethiopia, 2 each from Belarus, Colombia, and the Philippines, and 1 each from India, Kazakhstan, and Romania. At the time of adoption, 73% were under the age of 2 years.

With the exception of hepatitis B among children adopted from Korea and mumps among all children, the percentages of positive antibody titers were similar to rates reported in U.S. vaccine studies.

Of the children with records of DTP vaccine, 99% were titer positive for diphtheria antibody and 88% were titer positive for tetanus. Children with records of polio vaccine were 95% titer positive, those with records of measles vaccine were 92% titer positive, and those with reported rubella vaccine were 92% titer positive.

On the other hand, of children adopted from Asian countries other than China (28 of 31 of these children came from Korea), only 63% of those who had records of hepatitis B vaccine were titer positive.

The investigators suggested that the lower percentage of positive hepatitis B titers in children from Korea may be due to the manufacturing, storage, or administration of vaccine, but it is also plausible that Korean children have poorer responses to the vaccine.

Only 67% of all the adopted children with records of mumps vaccine had positive titers, which the investigators said was significantly lower than the percentage reported in U.S. vaccine studies. Investigators said that this may be attributable to issues with vaccine handling and storage, inaccurate record keeping, or an impaired immune response to the mumps vaccines used.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO – Opiates are often the best choice when treating pain in patients with HIV, but some of the available drugs can have limitations, Dr. Robert V. Brody said at a meeting on HIV management sponsored by the University of California, San Francisco.

Meperidine (Demerol), for example, is an opiate whose time has come and gone. “If you know a physician who still uses intramuscular Demerol for the management of pain like we did 30 years ago, you're in the presence of Tyrannosaurus rex,” said Dr. Robert V. Brody of San Francisco General Hospital.

In fact, this agent was removed from the San Francisco General Hospital formulary about 15 years ago. The problem is that although meperidine is a short-acting opiate, one of its metabolites accumulates. As patients continue to use the drug, they tend to get irritable, experience myoclonus, or, in some cases, develop seizures, he said.

Similarly, mixed agonist-antagonists like pentazocine or butorphanol (Stadol) have little use. They're difficult to titrate, and if a patient gets too high a dose, agitation and psychotomimetic effects can appear. Furthermore, since these drugs are part antagonist, it's difficult to simply discontinue them and give the patient something stronger, Dr. Brody said.

Tramadol, although not a bad drug, also has its limitations. Not chemically an opiate, tramadol occupies the μ opiate receptor and also has properties similar to SSRIs. It's prone to abuse and can be quite expensive, he said.

Buprenorphine is usually thought of in the context of opiate detox, but it's also mildly effective against pain. Its major limitation is that it binds so tightly, if the patient turns out to need something stronger, nothing is going to work very well. It's also quite expensive, Dr. Brody said.

Physicians often use fentanyl patches inappropriately. They should be used only for chronic, stable pain and never for postoperative or unpredictable pain. The onset of analgesia can take more than 12 hours, and fentanyl's effects can last more than 18 hours after the patch is removed. Adding another opiate to a fentanyl patch can easily result in an overdose, he noted.

SAN FRANCISCO – Opiates are often the best choice when treating pain in patients with HIV, but some of the available drugs can have limitations, Dr. Robert V. Brody said at a meeting on HIV management sponsored by the University of California, San Francisco.

Meperidine (Demerol), for example, is an opiate whose time has come and gone. “If you know a physician who still uses intramuscular Demerol for the management of pain like we did 30 years ago, you're in the presence of Tyrannosaurus rex,” said Dr. Robert V. Brody of San Francisco General Hospital.

In fact, this agent was removed from the San Francisco General Hospital formulary about 15 years ago. The problem is that although meperidine is a short-acting opiate, one of its metabolites accumulates. As patients continue to use the drug, they tend to get irritable, experience myoclonus, or, in some cases, develop seizures, he said.

Similarly, mixed agonist-antagonists like pentazocine or butorphanol (Stadol) have little use. They're difficult to titrate, and if a patient gets too high a dose, agitation and psychotomimetic effects can appear. Furthermore, since these drugs are part antagonist, it's difficult to simply discontinue them and give the patient something stronger, Dr. Brody said.

Tramadol, although not a bad drug, also has its limitations. Not chemically an opiate, tramadol occupies the μ opiate receptor and also has properties similar to SSRIs. It's prone to abuse and can be quite expensive, he said.

Buprenorphine is usually thought of in the context of opiate detox, but it's also mildly effective against pain. Its major limitation is that it binds so tightly, if the patient turns out to need something stronger, nothing is going to work very well. It's also quite expensive, Dr. Brody said.

Physicians often use fentanyl patches inappropriately. They should be used only for chronic, stable pain and never for postoperative or unpredictable pain. The onset of analgesia can take more than 12 hours, and fentanyl's effects can last more than 18 hours after the patch is removed. Adding another opiate to a fentanyl patch can easily result in an overdose, he noted.

SAN FRANCISCO – Opiates are often the best choice when treating pain in patients with HIV, but some of the available drugs can have limitations, Dr. Robert V. Brody said at a meeting on HIV management sponsored by the University of California, San Francisco.

Meperidine (Demerol), for example, is an opiate whose time has come and gone. “If you know a physician who still uses intramuscular Demerol for the management of pain like we did 30 years ago, you're in the presence of Tyrannosaurus rex,” said Dr. Robert V. Brody of San Francisco General Hospital.

In fact, this agent was removed from the San Francisco General Hospital formulary about 15 years ago. The problem is that although meperidine is a short-acting opiate, one of its metabolites accumulates. As patients continue to use the drug, they tend to get irritable, experience myoclonus, or, in some cases, develop seizures, he said.

Similarly, mixed agonist-antagonists like pentazocine or butorphanol (Stadol) have little use. They're difficult to titrate, and if a patient gets too high a dose, agitation and psychotomimetic effects can appear. Furthermore, since these drugs are part antagonist, it's difficult to simply discontinue them and give the patient something stronger, Dr. Brody said.

Tramadol, although not a bad drug, also has its limitations. Not chemically an opiate, tramadol occupies the μ opiate receptor and also has properties similar to SSRIs. It's prone to abuse and can be quite expensive, he said.

Buprenorphine is usually thought of in the context of opiate detox, but it's also mildly effective against pain. Its major limitation is that it binds so tightly, if the patient turns out to need something stronger, nothing is going to work very well. It's also quite expensive, Dr. Brody said.

Physicians often use fentanyl patches inappropriately. They should be used only for chronic, stable pain and never for postoperative or unpredictable pain. The onset of analgesia can take more than 12 hours, and fentanyl's effects can last more than 18 hours after the patch is removed. Adding another opiate to a fentanyl patch can easily result in an overdose, he noted.

SAN FRANCISCO – Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication, he said.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 53 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

After adjusting for child age and gender, primary household language, highest household educational attainment, and insurance status, autistic children had 21 times the risk of being judged in poor health and 7.7 times the risk of being judged in fair health, compared with nonautistic children.

Children with autism were 23 times more likely to be diagnosed with a behavioral or conduct disorder, 8 times more likely to have a diagnosis of ADHD, 15 times more likely to have a diagnosis of depression or anxiety, 4.5 times more likely to have a food allergy, and 2.4 times more likely to suffer from headache.

Children with autism had much more interaction with the medical system than those without, with parents mentioning significantly more preventive-care visits, nonemergency visits, and emergency visits during the previous 12 months. Ten percent of children with autism paid two or more visits to the emergency department during that period, compared with 4.9% of children without autism.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. “I bring this up because it's not unusual to hear that these parents are very high maintenance.”

SAN FRANCISCO – Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication, he said.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 53 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

After adjusting for child age and gender, primary household language, highest household educational attainment, and insurance status, autistic children had 21 times the risk of being judged in poor health and 7.7 times the risk of being judged in fair health, compared with nonautistic children.

Children with autism were 23 times more likely to be diagnosed with a behavioral or conduct disorder, 8 times more likely to have a diagnosis of ADHD, 15 times more likely to have a diagnosis of depression or anxiety, 4.5 times more likely to have a food allergy, and 2.4 times more likely to suffer from headache.

Children with autism had much more interaction with the medical system than those without, with parents mentioning significantly more preventive-care visits, nonemergency visits, and emergency visits during the previous 12 months. Ten percent of children with autism paid two or more visits to the emergency department during that period, compared with 4.9% of children without autism.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. “I bring this up because it's not unusual to hear that these parents are very high maintenance.”

SAN FRANCISCO – Data from a large national survey document very high levels of comorbidity among children with autism, James G. Gurney, Ph.D., reported at the annual meeting of the Pediatric Academic Societies.

Compared with children aged 3–17 years without autism, those with autism are 21 times more likely to be in poor health; are about 40 times more likely to be receiving speech therapy, behavioral treatment, or counseling; and are 11 times more likely to be using long-term medication, he said.

“Children with autism present with unusually complex emotional, behavioral, and medical needs,” said Dr. Gurney of the University of Michigan, Ann Arbor. “Generalists may need to coordinate care among a variety of subspecialty consultants and service providers. And given the increasing prevalence of autism, pediatricians may find that they have to confront this type of situation much more than they used to.”

Dr. Gurney and his colleagues used data from the Centers for Disease Control and Prevention's National Survey of Children's Health, a cross-sectional, population-based sample from 2003–2004 of more than 100,000 parents. Extrapolated to the entire U.S. population with stratified weighted sampling fractions, the investigators estimated the prevalence of autism at 53 per 100,000 children, an estimated total of 324,000 children nationwide.

In general, parents of children with autism judged their child's health to be significantly worse than did parents of children without autism. Parents judged 3.5% of their children with autism to be in poor health and 7.9% to be in fair health, compared with 0.4% and 2.9%, respectively, among nonautistic children.

After adjusting for child age and gender, primary household language, highest household educational attainment, and insurance status, autistic children had 21 times the risk of being judged in poor health and 7.7 times the risk of being judged in fair health, compared with nonautistic children.

Children with autism were 23 times more likely to be diagnosed with a behavioral or conduct disorder, 8 times more likely to have a diagnosis of ADHD, 15 times more likely to have a diagnosis of depression or anxiety, 4.5 times more likely to have a food allergy, and 2.4 times more likely to suffer from headache.

Children with autism had much more interaction with the medical system than those without, with parents mentioning significantly more preventive-care visits, nonemergency visits, and emergency visits during the previous 12 months. Ten percent of children with autism paid two or more visits to the emergency department during that period, compared with 4.9% of children without autism.

“Although not directly addressed in the study, these results speak to the heavy responsibilities that parents bear in caring for a child with autism,” Dr. Gurney said at the meeting sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics. “I bring this up because it's not unusual to hear that these parents are very high maintenance.”

SAN FRANCISCO — The amount of plant food adolescents eat is a better predictor of cardiovascular risk than is their intake of cholesterol or saturated fat, according to a poster presentation by Dr. Karen A. Ortiz at the annual meeting of the Pediatric Academic Societies.

Using data from 2,128 adolescents aged 12–19 years, taken from the National Health and Nutrition Examination Survey, Dr. Ortiz, who was then at the University of Utah, Salt Lake City, and her colleagues determined that the amount of plant food the adolescents recalled eating within the previous 24 hours was significantly inversely correlated with the presence of the metabolic syndrome. For each quintile increase in that index, there was a statistically significant decrease of 20% in the prevalence of metabolic syndrome.

The amount of cholesterol and saturated fat in the dietary recall showed no significant correlation with the metabolic syndrome or its component risk factors.

On the basis of dietary recall, Dr. Ortiz, now a pediatrician in private practice in Santa Fe, N.M., calculated a plant-based food index (grams of fiber per 1,000 kcal), a saturated fat index (grams of saturated fat per 1,000 kcal), and a cholesterol index (grams of cholesterol per 1,000 kcal).

The presence of metabolic syndrome was defined as abnormalities in any three of five domains: triglycerides, HDL cholesterol, waist circumference, fasting glucose levels, and blood pressure. Metabolic syndrome was present in 7% of the teens.

None of the dietary indices was associated with levels of homocysteine, C-reactive protein, or hemoglobin A_1c. All analyses in the logistic regression were adjusted for gender, age, ethnicity, family income, and other nutrient indices.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — The amount of plant food adolescents eat is a better predictor of cardiovascular risk than is their intake of cholesterol or saturated fat, according to a poster presentation by Dr. Karen A. Ortiz at the annual meeting of the Pediatric Academic Societies.

Using data from 2,128 adolescents aged 12–19 years, taken from the National Health and Nutrition Examination Survey, Dr. Ortiz, who was then at the University of Utah, Salt Lake City, and her colleagues determined that the amount of plant food the adolescents recalled eating within the previous 24 hours was significantly inversely correlated with the presence of the metabolic syndrome. For each quintile increase in that index, there was a statistically significant decrease of 20% in the prevalence of metabolic syndrome.

The amount of cholesterol and saturated fat in the dietary recall showed no significant correlation with the metabolic syndrome or its component risk factors.

On the basis of dietary recall, Dr. Ortiz, now a pediatrician in private practice in Santa Fe, N.M., calculated a plant-based food index (grams of fiber per 1,000 kcal), a saturated fat index (grams of saturated fat per 1,000 kcal), and a cholesterol index (grams of cholesterol per 1,000 kcal).

The presence of metabolic syndrome was defined as abnormalities in any three of five domains: triglycerides, HDL cholesterol, waist circumference, fasting glucose levels, and blood pressure. Metabolic syndrome was present in 7% of the teens.

None of the dietary indices was associated with levels of homocysteine, C-reactive protein, or hemoglobin A_1c. All analyses in the logistic regression were adjusted for gender, age, ethnicity, family income, and other nutrient indices.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.

SAN FRANCISCO — The amount of plant food adolescents eat is a better predictor of cardiovascular risk than is their intake of cholesterol or saturated fat, according to a poster presentation by Dr. Karen A. Ortiz at the annual meeting of the Pediatric Academic Societies.

Using data from 2,128 adolescents aged 12–19 years, taken from the National Health and Nutrition Examination Survey, Dr. Ortiz, who was then at the University of Utah, Salt Lake City, and her colleagues determined that the amount of plant food the adolescents recalled eating within the previous 24 hours was significantly inversely correlated with the presence of the metabolic syndrome. For each quintile increase in that index, there was a statistically significant decrease of 20% in the prevalence of metabolic syndrome.

The amount of cholesterol and saturated fat in the dietary recall showed no significant correlation with the metabolic syndrome or its component risk factors.

On the basis of dietary recall, Dr. Ortiz, now a pediatrician in private practice in Santa Fe, N.M., calculated a plant-based food index (grams of fiber per 1,000 kcal), a saturated fat index (grams of saturated fat per 1,000 kcal), and a cholesterol index (grams of cholesterol per 1,000 kcal).

The presence of metabolic syndrome was defined as abnormalities in any three of five domains: triglycerides, HDL cholesterol, waist circumference, fasting glucose levels, and blood pressure. Metabolic syndrome was present in 7% of the teens.

None of the dietary indices was associated with levels of homocysteine, C-reactive protein, or hemoglobin A_1c. All analyses in the logistic regression were adjusted for gender, age, ethnicity, family income, and other nutrient indices.

The meeting was sponsored by the American Pediatric Society, Society for Pediatric Research, Ambulatory Pediatric Association, and American Academy of Pediatrics.