Diana Mahoney

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to an analysis of the health information for 121,965 men and women examined at a large French medical center during 1999–2006.

In that study, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

The investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Impaired lung function was defined as a forced expiratory volume in 1 second (FEV₁) or forced vital capacity (FVC) less than the lower limit of normal. In the logistic regression model, impaired FEV₁ and FVC were independently linked to metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low HDL cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” wrote the authors, who reported having no relevant financial conflicts of interest.

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to an analysis of the health information for 121,965 men and women examined at a large French medical center during 1999–2006.

In that study, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

The investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Impaired lung function was defined as a forced expiratory volume in 1 second (FEV₁) or forced vital capacity (FVC) less than the lower limit of normal. In the logistic regression model, impaired FEV₁ and FVC were independently linked to metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low HDL cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” wrote the authors, who reported having no relevant financial conflicts of interest.

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to an analysis of the health information for 121,965 men and women examined at a large French medical center during 1999–2006.

In that study, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

The investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Impaired lung function was defined as a forced expiratory volume in 1 second (FEV₁) or forced vital capacity (FVC) less than the lower limit of normal. In the logistic regression model, impaired FEV₁ and FVC were independently linked to metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low HDL cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” wrote the authors, who reported having no relevant financial conflicts of interest.

Residual soft tissue and bone edema associated with diagnostic or surgical intervention for suspected osteomyelitis or septic arthritis does not diminish the value of subsequent magnetic resonance imaging in children with persistent signs of infection, a study has shown.

The issue under investigation was whether iatrogenic injury to soft tissue or marrow before an MRI study interferes with the clinician's ability to exclude infection or diagnose alternative causes for symptoms that remain despite a negative result after intervention.

Dr. J. Herman Kan of Vanderbilt Children's Hospital, Nashville, Tenn., and his colleagues conducted a retrospective case-control study using data from patients who underwent emergent contrast-enhanced MRI examinations that were performed for suspected osteomyelitis or septic arthritis at the hospital from March 2002 through September 2007.

Of the initial 136 MRI examinations, the analysis included only the 34 performed within 10 days after an initial diagnostic or surgical intervention, such as joint, marrow, or soft-tissue aspiration; arthrotomy; or incision and drainage of bone or soft tissue. The study control group consisted of 96 patients who underwent MRI for suspected osteomyelitis or septic arthritis during the same period but who did not have a prior intervention.

Pediatric radiologists with additional training in pediatric musculoskeletal radiology performed consensus reviews of the images to assess whether objective MRI criteria could still be applied to those patients who had undergone recent intervention. They also evaluated the presence or absence of specific MRI features of osteomyelitis that could neither be attributed to the recent intervention nor were suggestive of a noninfectious alternative diagnosis. Such features included intraosseous abscess, cortical breach, subperiosteal abscess, and soft-tissue or bone edema, the authors wrote.

The reviewing radiologists had knowledge of the location of the prior intervention and the final discharge diagnosis, they noted (Am. J. Roentgenol. 2008;191:1595–600).

In 10 of the 34 study group patients (29%), the MRI findings led to a need for additional intervention, which was similar to the control group, in which the MRI findings pointed to further intervention for 26 of the 96 control group patients (27%), Dr. Kan and his associates reported.

The groups did not differ significantly in the number of patients with a final diagnosis of osteomyelitis, osteomyelitis or septic arthritis, cellulitis or pyomyositis, and noninfectious conditions, they stated.

A total of nine patients in the study population had a final diagnosis of osteomyelitis, and “objective MRI criteria were present in all nine patients,” the authors said, while none of the remaining 25 patients had characteristic imaging features of osteomyelitis.

Among the patients with an osteomyelitis diagnosis, “eight of nine had one or more imaging criteria of osteomyelitis, including intraosseous abscess, cortical breach, or subperiosteal abscess,” Dr. Kan and his associates said.

The ninth subject was diagnosed with acetabular osteomyelitis based on evidence of marrow and soft-tissue edema in the obturator internus muscle, away from the intervention site.

The findings suggest that musculoskeletal MRI “plays an important role in the management of these patients because of its ability to evaluate underlying osteomyelitis despite recent intervention,” according to the authors.

With correct clinical and surgical history, they wrote, “patterns of soft tissue and marrow edema can be explained.”

Although intervention-related iatrogenic changes do not affect the diagnostic efficacy of MRI in children with suspected osteomyelitis or septic arthritis, “performing MRI before intervention adds efficacy to patient management, guides the surgical procedure, and prevents additional surgery in children with suspected pelvic or appendicular osteomyelitis or septic arthritis,” Dr. Kan and his associates concluded.

Right foot after administration of IV gadolinium shows large soft tissue abscess (arrows) and intraosseous calcaneal abscess (arrowhead).

T2-weighted distal humerus is shown with intramedullary abscess.

Corresponding T1-weighted image of humerus shows subperiosteal abscess. Images courtesy Dr. J. Herman Kan

Residual soft tissue and bone edema associated with diagnostic or surgical intervention for suspected osteomyelitis or septic arthritis does not diminish the value of subsequent magnetic resonance imaging in children with persistent signs of infection, a study has shown.

The issue under investigation was whether iatrogenic injury to soft tissue or marrow before an MRI study interferes with the clinician's ability to exclude infection or diagnose alternative causes for symptoms that remain despite a negative result after intervention.

Dr. J. Herman Kan of Vanderbilt Children's Hospital, Nashville, Tenn., and his colleagues conducted a retrospective case-control study using data from patients who underwent emergent contrast-enhanced MRI examinations that were performed for suspected osteomyelitis or septic arthritis at the hospital from March 2002 through September 2007.

Of the initial 136 MRI examinations, the analysis included only the 34 performed within 10 days after an initial diagnostic or surgical intervention, such as joint, marrow, or soft-tissue aspiration; arthrotomy; or incision and drainage of bone or soft tissue. The study control group consisted of 96 patients who underwent MRI for suspected osteomyelitis or septic arthritis during the same period but who did not have a prior intervention.

Pediatric radiologists with additional training in pediatric musculoskeletal radiology performed consensus reviews of the images to assess whether objective MRI criteria could still be applied to those patients who had undergone recent intervention. They also evaluated the presence or absence of specific MRI features of osteomyelitis that could neither be attributed to the recent intervention nor were suggestive of a noninfectious alternative diagnosis. Such features included intraosseous abscess, cortical breach, subperiosteal abscess, and soft-tissue or bone edema, the authors wrote.

The reviewing radiologists had knowledge of the location of the prior intervention and the final discharge diagnosis, they noted (Am. J. Roentgenol. 2008;191:1595–600).

In 10 of the 34 study group patients (29%), the MRI findings led to a need for additional intervention, which was similar to the control group, in which the MRI findings pointed to further intervention for 26 of the 96 control group patients (27%), Dr. Kan and his associates reported.

The groups did not differ significantly in the number of patients with a final diagnosis of osteomyelitis, osteomyelitis or septic arthritis, cellulitis or pyomyositis, and noninfectious conditions, they stated.

A total of nine patients in the study population had a final diagnosis of osteomyelitis, and “objective MRI criteria were present in all nine patients,” the authors said, while none of the remaining 25 patients had characteristic imaging features of osteomyelitis.

Among the patients with an osteomyelitis diagnosis, “eight of nine had one or more imaging criteria of osteomyelitis, including intraosseous abscess, cortical breach, or subperiosteal abscess,” Dr. Kan and his associates said.

The ninth subject was diagnosed with acetabular osteomyelitis based on evidence of marrow and soft-tissue edema in the obturator internus muscle, away from the intervention site.

The findings suggest that musculoskeletal MRI “plays an important role in the management of these patients because of its ability to evaluate underlying osteomyelitis despite recent intervention,” according to the authors.

With correct clinical and surgical history, they wrote, “patterns of soft tissue and marrow edema can be explained.”

Although intervention-related iatrogenic changes do not affect the diagnostic efficacy of MRI in children with suspected osteomyelitis or septic arthritis, “performing MRI before intervention adds efficacy to patient management, guides the surgical procedure, and prevents additional surgery in children with suspected pelvic or appendicular osteomyelitis or septic arthritis,” Dr. Kan and his associates concluded.

Right foot after administration of IV gadolinium shows large soft tissue abscess (arrows) and intraosseous calcaneal abscess (arrowhead).

T2-weighted distal humerus is shown with intramedullary abscess.

Corresponding T1-weighted image of humerus shows subperiosteal abscess. Images courtesy Dr. J. Herman Kan

Residual soft tissue and bone edema associated with diagnostic or surgical intervention for suspected osteomyelitis or septic arthritis does not diminish the value of subsequent magnetic resonance imaging in children with persistent signs of infection, a study has shown.

The issue under investigation was whether iatrogenic injury to soft tissue or marrow before an MRI study interferes with the clinician's ability to exclude infection or diagnose alternative causes for symptoms that remain despite a negative result after intervention.

Dr. J. Herman Kan of Vanderbilt Children's Hospital, Nashville, Tenn., and his colleagues conducted a retrospective case-control study using data from patients who underwent emergent contrast-enhanced MRI examinations that were performed for suspected osteomyelitis or septic arthritis at the hospital from March 2002 through September 2007.

Of the initial 136 MRI examinations, the analysis included only the 34 performed within 10 days after an initial diagnostic or surgical intervention, such as joint, marrow, or soft-tissue aspiration; arthrotomy; or incision and drainage of bone or soft tissue. The study control group consisted of 96 patients who underwent MRI for suspected osteomyelitis or septic arthritis during the same period but who did not have a prior intervention.

Pediatric radiologists with additional training in pediatric musculoskeletal radiology performed consensus reviews of the images to assess whether objective MRI criteria could still be applied to those patients who had undergone recent intervention. They also evaluated the presence or absence of specific MRI features of osteomyelitis that could neither be attributed to the recent intervention nor were suggestive of a noninfectious alternative diagnosis. Such features included intraosseous abscess, cortical breach, subperiosteal abscess, and soft-tissue or bone edema, the authors wrote.

The reviewing radiologists had knowledge of the location of the prior intervention and the final discharge diagnosis, they noted (Am. J. Roentgenol. 2008;191:1595–600).

In 10 of the 34 study group patients (29%), the MRI findings led to a need for additional intervention, which was similar to the control group, in which the MRI findings pointed to further intervention for 26 of the 96 control group patients (27%), Dr. Kan and his associates reported.

The groups did not differ significantly in the number of patients with a final diagnosis of osteomyelitis, osteomyelitis or septic arthritis, cellulitis or pyomyositis, and noninfectious conditions, they stated.

A total of nine patients in the study population had a final diagnosis of osteomyelitis, and “objective MRI criteria were present in all nine patients,” the authors said, while none of the remaining 25 patients had characteristic imaging features of osteomyelitis.

Among the patients with an osteomyelitis diagnosis, “eight of nine had one or more imaging criteria of osteomyelitis, including intraosseous abscess, cortical breach, or subperiosteal abscess,” Dr. Kan and his associates said.

The ninth subject was diagnosed with acetabular osteomyelitis based on evidence of marrow and soft-tissue edema in the obturator internus muscle, away from the intervention site.

The findings suggest that musculoskeletal MRI “plays an important role in the management of these patients because of its ability to evaluate underlying osteomyelitis despite recent intervention,” according to the authors.

With correct clinical and surgical history, they wrote, “patterns of soft tissue and marrow edema can be explained.”

Although intervention-related iatrogenic changes do not affect the diagnostic efficacy of MRI in children with suspected osteomyelitis or septic arthritis, “performing MRI before intervention adds efficacy to patient management, guides the surgical procedure, and prevents additional surgery in children with suspected pelvic or appendicular osteomyelitis or septic arthritis,” Dr. Kan and his associates concluded.

Right foot after administration of IV gadolinium shows large soft tissue abscess (arrows) and intraosseous calcaneal abscess (arrowhead).

T2-weighted distal humerus is shown with intramedullary abscess.

Corresponding T1-weighted image of humerus shows subperiosteal abscess. Images courtesy Dr. J. Herman Kan

New data indicating that a first simple febrile seizure in infants and young children rarely signals bacterial meningitis suggest that the American Academy of Pediatrics' recommendation of lumbar puncture in this population should be reconsidered, according to investigators from Children's Hospital Boston.

In its 1996 practice parameter for the neurodiagnostic evaluation of children with a first simple febrile seizure (FSFS), the American Academy of Pediatrics recommended that lumbar puncture be strongly considered for infants younger than 12 months of age, and that it be considered for those between 12 and 18 months of age who present within 12 hours of the event. The rationale for the recommendation was that bacterial meningitis commonly presents with seizure, and the identification of subtle signs of the infection via clinical assessment can be difficult and is dependent on the skill level and experience of the clinician (Pediatrics 1996;97:769–72).

To determine compliance with the AAP recommendations and to assess the rate of bacterial meningitis in young children, Dr. Amir A. Kimia and colleagues in the division of emergency medicine at Children's Hospital Boston performed a retrospective cohort review for patients aged 6–18 months who were evaluated for FSFS in the hospital's emergency department (ED) between October 1995 and October 2006. Of the 71,234 ED visits for children aged 6–18 months during the study period, 704 were for otherwise healthy children presenting with FSFS, including 188 for children younger than 12 months and 516 for children aged 12–18 months.

Lumbar puncture was attempted in 271 of the 704 (38%) children, and cerebrospinal fluid (CSF) was successfully obtained in 260 of them, including 131 of the children aged at least 6 months but younger than 12 months and 129 of the 12- to 18-month-olds. Cerebrospinal fluid pleocytosis was found in 10 of the 260 samples and no pathogen was identified in CSF cultures.

“None of the 10 patients with CSF pleocytosis had isolation of bacteria from blood cultures,” they reported, and “none of the 704 patients with FSFS returned to the hospital with a diagnosis of bacterial meningitis” (Pediatrics 2009;123:6–12). Among the remaining 70,530 children aged 6–18 months without FSFS who were seen in the ED during the same period, 8 were diagnosed with bacterial meningitis, they noted.

When compliance with the AAP recommendations was considered, the performance of lumbar punctures during the study period decreased significantly, from 70% for infants younger than 12 months old to 25% for infants aged 12–18 months, according to Dr. Kimia and associates, who also observed that “rates of [lumbar puncture] performance decreased over time in both age groups.”

The 38% rate of lumber punctures performed at Children's Hospital Boston, a pediatric tertiary care facility, was significantly higher than that which has been reported for children aged younger than 18 months who received care in community EDs, the authors noted.

This fact—combined with the finding that it is very rare for bacterial meningitis to present as FSFS—suggests that the AAP practice parameters “have limited utility,” the authors wrote. Given the lack of evidence to support a recommendation of lumbar puncture for first simple febrile seizures in young children, “the [AAP] recommendations should be changed to state simply that meningitis should be considered in the differential diagnosis for any febrile child and [lumbar puncture] should be performed if there are clinical signs or symptoms of concern.”

The chair of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Dr. Kathy N. Shaw, disagreed with the authors' conclusion.

“A lumbar puncture should be considered in all children who present with a simple febrile seizure,” Dr. Shaw said in an interview. In fact, she noted, “the possibility of meningitis should always be considered in the emergency department evaluation of young, febrile infants. The younger the age, the more difficult it is to use clinical judgment alone, and the lower the threshold for performing a lumbar puncture. This statement is true regardless of whether the infant had a seizure or not.”

Regarding the authors' suggestion that the AAP remove the word “strongly” from the recommendation for lumbar puncture for infants aged at least 6 months but younger than 12 months, “data from a single academic institution, especially one staffed by pediatric emergency medicine specialists who evaluate febrile infants in the acute setting routinely, [are] not enough to change recommendations,” said Dr. Shaw, a professor of pediatrics at the Children's Hospital of Philadelphia.

Dr. Kimia and associates did acknowledge that sound clinical judgment and erring on the side of caution should always prevail “when evaluating any febrile child for whom the presence of bacterial meningitis is being considered.”

The authors reported having no relevant financial conflicts of interest.

New data indicating that a first simple febrile seizure in infants and young children rarely signals bacterial meningitis suggest that the American Academy of Pediatrics' recommendation of lumbar puncture in this population should be reconsidered, according to investigators from Children's Hospital Boston.

In its 1996 practice parameter for the neurodiagnostic evaluation of children with a first simple febrile seizure (FSFS), the American Academy of Pediatrics recommended that lumbar puncture be strongly considered for infants younger than 12 months of age, and that it be considered for those between 12 and 18 months of age who present within 12 hours of the event. The rationale for the recommendation was that bacterial meningitis commonly presents with seizure, and the identification of subtle signs of the infection via clinical assessment can be difficult and is dependent on the skill level and experience of the clinician (Pediatrics 1996;97:769–72).

To determine compliance with the AAP recommendations and to assess the rate of bacterial meningitis in young children, Dr. Amir A. Kimia and colleagues in the division of emergency medicine at Children's Hospital Boston performed a retrospective cohort review for patients aged 6–18 months who were evaluated for FSFS in the hospital's emergency department (ED) between October 1995 and October 2006. Of the 71,234 ED visits for children aged 6–18 months during the study period, 704 were for otherwise healthy children presenting with FSFS, including 188 for children younger than 12 months and 516 for children aged 12–18 months.

Lumbar puncture was attempted in 271 of the 704 (38%) children, and cerebrospinal fluid (CSF) was successfully obtained in 260 of them, including 131 of the children aged at least 6 months but younger than 12 months and 129 of the 12- to 18-month-olds. Cerebrospinal fluid pleocytosis was found in 10 of the 260 samples and no pathogen was identified in CSF cultures.

“None of the 10 patients with CSF pleocytosis had isolation of bacteria from blood cultures,” they reported, and “none of the 704 patients with FSFS returned to the hospital with a diagnosis of bacterial meningitis” (Pediatrics 2009;123:6–12). Among the remaining 70,530 children aged 6–18 months without FSFS who were seen in the ED during the same period, 8 were diagnosed with bacterial meningitis, they noted.

When compliance with the AAP recommendations was considered, the performance of lumbar punctures during the study period decreased significantly, from 70% for infants younger than 12 months old to 25% for infants aged 12–18 months, according to Dr. Kimia and associates, who also observed that “rates of [lumbar puncture] performance decreased over time in both age groups.”

The 38% rate of lumber punctures performed at Children's Hospital Boston, a pediatric tertiary care facility, was significantly higher than that which has been reported for children aged younger than 18 months who received care in community EDs, the authors noted.

This fact—combined with the finding that it is very rare for bacterial meningitis to present as FSFS—suggests that the AAP practice parameters “have limited utility,” the authors wrote. Given the lack of evidence to support a recommendation of lumbar puncture for first simple febrile seizures in young children, “the [AAP] recommendations should be changed to state simply that meningitis should be considered in the differential diagnosis for any febrile child and [lumbar puncture] should be performed if there are clinical signs or symptoms of concern.”

The chair of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Dr. Kathy N. Shaw, disagreed with the authors' conclusion.

“A lumbar puncture should be considered in all children who present with a simple febrile seizure,” Dr. Shaw said in an interview. In fact, she noted, “the possibility of meningitis should always be considered in the emergency department evaluation of young, febrile infants. The younger the age, the more difficult it is to use clinical judgment alone, and the lower the threshold for performing a lumbar puncture. This statement is true regardless of whether the infant had a seizure or not.”

Regarding the authors' suggestion that the AAP remove the word “strongly” from the recommendation for lumbar puncture for infants aged at least 6 months but younger than 12 months, “data from a single academic institution, especially one staffed by pediatric emergency medicine specialists who evaluate febrile infants in the acute setting routinely, [are] not enough to change recommendations,” said Dr. Shaw, a professor of pediatrics at the Children's Hospital of Philadelphia.

Dr. Kimia and associates did acknowledge that sound clinical judgment and erring on the side of caution should always prevail “when evaluating any febrile child for whom the presence of bacterial meningitis is being considered.”

The authors reported having no relevant financial conflicts of interest.

New data indicating that a first simple febrile seizure in infants and young children rarely signals bacterial meningitis suggest that the American Academy of Pediatrics' recommendation of lumbar puncture in this population should be reconsidered, according to investigators from Children's Hospital Boston.

In its 1996 practice parameter for the neurodiagnostic evaluation of children with a first simple febrile seizure (FSFS), the American Academy of Pediatrics recommended that lumbar puncture be strongly considered for infants younger than 12 months of age, and that it be considered for those between 12 and 18 months of age who present within 12 hours of the event. The rationale for the recommendation was that bacterial meningitis commonly presents with seizure, and the identification of subtle signs of the infection via clinical assessment can be difficult and is dependent on the skill level and experience of the clinician (Pediatrics 1996;97:769–72).

To determine compliance with the AAP recommendations and to assess the rate of bacterial meningitis in young children, Dr. Amir A. Kimia and colleagues in the division of emergency medicine at Children's Hospital Boston performed a retrospective cohort review for patients aged 6–18 months who were evaluated for FSFS in the hospital's emergency department (ED) between October 1995 and October 2006. Of the 71,234 ED visits for children aged 6–18 months during the study period, 704 were for otherwise healthy children presenting with FSFS, including 188 for children younger than 12 months and 516 for children aged 12–18 months.

Lumbar puncture was attempted in 271 of the 704 (38%) children, and cerebrospinal fluid (CSF) was successfully obtained in 260 of them, including 131 of the children aged at least 6 months but younger than 12 months and 129 of the 12- to 18-month-olds. Cerebrospinal fluid pleocytosis was found in 10 of the 260 samples and no pathogen was identified in CSF cultures.

“None of the 10 patients with CSF pleocytosis had isolation of bacteria from blood cultures,” they reported, and “none of the 704 patients with FSFS returned to the hospital with a diagnosis of bacterial meningitis” (Pediatrics 2009;123:6–12). Among the remaining 70,530 children aged 6–18 months without FSFS who were seen in the ED during the same period, 8 were diagnosed with bacterial meningitis, they noted.

When compliance with the AAP recommendations was considered, the performance of lumbar punctures during the study period decreased significantly, from 70% for infants younger than 12 months old to 25% for infants aged 12–18 months, according to Dr. Kimia and associates, who also observed that “rates of [lumbar puncture] performance decreased over time in both age groups.”

The 38% rate of lumber punctures performed at Children's Hospital Boston, a pediatric tertiary care facility, was significantly higher than that which has been reported for children aged younger than 18 months who received care in community EDs, the authors noted.

This fact—combined with the finding that it is very rare for bacterial meningitis to present as FSFS—suggests that the AAP practice parameters “have limited utility,” the authors wrote. Given the lack of evidence to support a recommendation of lumbar puncture for first simple febrile seizures in young children, “the [AAP] recommendations should be changed to state simply that meningitis should be considered in the differential diagnosis for any febrile child and [lumbar puncture] should be performed if there are clinical signs or symptoms of concern.”

The chair of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Dr. Kathy N. Shaw, disagreed with the authors' conclusion.

“A lumbar puncture should be considered in all children who present with a simple febrile seizure,” Dr. Shaw said in an interview. In fact, she noted, “the possibility of meningitis should always be considered in the emergency department evaluation of young, febrile infants. The younger the age, the more difficult it is to use clinical judgment alone, and the lower the threshold for performing a lumbar puncture. This statement is true regardless of whether the infant had a seizure or not.”

Regarding the authors' suggestion that the AAP remove the word “strongly” from the recommendation for lumbar puncture for infants aged at least 6 months but younger than 12 months, “data from a single academic institution, especially one staffed by pediatric emergency medicine specialists who evaluate febrile infants in the acute setting routinely, [are] not enough to change recommendations,” said Dr. Shaw, a professor of pediatrics at the Children's Hospital of Philadelphia.

Dr. Kimia and associates did acknowledge that sound clinical judgment and erring on the side of caution should always prevail “when evaluating any febrile child for whom the presence of bacterial meningitis is being considered.”

The authors reported having no relevant financial conflicts of interest.

The American College of Allergy, Asthma & Immunology is offering free asthma screenings for adults and children at more than 200 sites across the country. Most screenings will take play in May. For a list of locations and dates, visit the National Asthma Screening Program at www.acaai.org/public/lifeQuality/nasp/index.htm

The American College of Allergy, Asthma & Immunology is offering free asthma screenings for adults and children at more than 200 sites across the country. Most screenings will take play in May. For a list of locations and dates, visit the National Asthma Screening Program at www.acaai.org/public/lifeQuality/nasp/index.htm

The American College of Allergy, Asthma & Immunology is offering free asthma screenings for adults and children at more than 200 sites across the country. Most screenings will take play in May. For a list of locations and dates, visit the National Asthma Screening Program at www.acaai.org/public/lifeQuality/nasp/index.htm

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to findings from a population analysis.

In an analysis of the health information for 121,965 men and women examined at a large French medical center between 1999 and 2006, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes. Waist circumference was the strongest predictor of the respiratory disturbance (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

Based on the new evidence, the measurement of waist circumference should be routine practice before spirometry tests, Dr. Paul Enright of the University of Arizona in Tucson suggested in an accompanying editorial.

“Abdominal obesity could then be highlighted on the printed report so that the physician interpreting the report could take the effect of obesity into account,” Dr. Enright noted (Am. J. Respir. Crit. Care Med. 2009;179:432–3).

Previous studies have linked impaired lung function with an increased risk of cardiovascular morbidity and mortality, but the mechanisms underlying the association have not been identified, the authors wrote.

Hypothesizing that metabolic syndrome or specific combinations of its components might play an important role in the relationship, the investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Lung function measures included forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Impaired lung function was defined as an FEV1 or FVC less than the lower limit of normal, the authors wrote. Metabolic syndrome was assessed according to American Heart Association and National Heart, Lung, and Blood Institute guidelines.

In the logistic regression model, impaired FEV1 and FVC were independently associated with metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low high-density lipoprotein cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. The relationship was not significantly modified by smoking status or BMI category, and it persisted after the exclusion of individuals with a history of cardiovascular or respiratory diseases.

Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” the authors wrote.

“Prospective studies are needed to determine the temporal relationship between lung function impairment and metabolic syndrome, including abdominal adiposity in particular,” they said.

Mechanistic studies are warranted to clarify the underlying physiopathological pathways, the investigators added.

The authors of the study and the editorial reported having no relevant financial conflicts of interest.

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to findings from a population analysis.

In an analysis of the health information for 121,965 men and women examined at a large French medical center between 1999 and 2006, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes. Waist circumference was the strongest predictor of the respiratory disturbance (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

Based on the new evidence, the measurement of waist circumference should be routine practice before spirometry tests, Dr. Paul Enright of the University of Arizona in Tucson suggested in an accompanying editorial.

“Abdominal obesity could then be highlighted on the printed report so that the physician interpreting the report could take the effect of obesity into account,” Dr. Enright noted (Am. J. Respir. Crit. Care Med. 2009;179:432–3).

Previous studies have linked impaired lung function with an increased risk of cardiovascular morbidity and mortality, but the mechanisms underlying the association have not been identified, the authors wrote.

Hypothesizing that metabolic syndrome or specific combinations of its components might play an important role in the relationship, the investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Lung function measures included forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Impaired lung function was defined as an FEV1 or FVC less than the lower limit of normal, the authors wrote. Metabolic syndrome was assessed according to American Heart Association and National Heart, Lung, and Blood Institute guidelines.

In the logistic regression model, impaired FEV1 and FVC were independently associated with metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low high-density lipoprotein cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. The relationship was not significantly modified by smoking status or BMI category, and it persisted after the exclusion of individuals with a history of cardiovascular or respiratory diseases.

Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” the authors wrote.

“Prospective studies are needed to determine the temporal relationship between lung function impairment and metabolic syndrome, including abdominal adiposity in particular,” they said.

Mechanistic studies are warranted to clarify the underlying physiopathological pathways, the investigators added.

The authors of the study and the editorial reported having no relevant financial conflicts of interest.

Abdominal obesity may be a key determinant in the link between metabolic syndrome and impaired lung function, according to findings from a population analysis.

In an analysis of the health information for 121,965 men and women examined at a large French medical center between 1999 and 2006, Dr. Nathalie Leone of the University of Paris 7-Denis Diderot in France and colleagues observed a positive, independent relationship between impaired lung function and metabolic syndrome in both sexes. Waist circumference was the strongest predictor of the respiratory disturbance (Am. J. Respir. Crit. Care Med. 2009;179:509–16).

Based on the new evidence, the measurement of waist circumference should be routine practice before spirometry tests, Dr. Paul Enright of the University of Arizona in Tucson suggested in an accompanying editorial.

“Abdominal obesity could then be highlighted on the printed report so that the physician interpreting the report could take the effect of obesity into account,” Dr. Enright noted (Am. J. Respir. Crit. Care Med. 2009;179:432–3).

Previous studies have linked impaired lung function with an increased risk of cardiovascular morbidity and mortality, but the mechanisms underlying the association have not been identified, the authors wrote.

Hypothesizing that metabolic syndrome or specific combinations of its components might play an important role in the relationship, the investigators evaluated the risk for impaired lung function according to metabolic syndrome traits using a logistic regression model adjusted for age, sex, education, smoking status, alcohol, BMI, physical activity, and cardiovascular disease history.

Lung function measures included forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Impaired lung function was defined as an FEV1 or FVC less than the lower limit of normal, the authors wrote. Metabolic syndrome was assessed according to American Heart Association and National Heart, Lung, and Blood Institute guidelines.

In the logistic regression model, impaired FEV1 and FVC were independently associated with metabolic syndrome, with odds ratios of 1.28 and 1.41, respectively. Similar results were observed in women and men, the authors reported.

Metabolic syndrome variables identified three factors independently associated with impaired lung function: low high-density lipoprotein cholesterol level/high triglyceride level, high fasting glucose level/high blood pressure, and waist circumference greater than 35 inches for women and greater than 40 inches for men.

Abdominal obesity showed the strongest association with lung function. The relationship was not significantly modified by smoking status or BMI category, and it persisted after the exclusion of individuals with a history of cardiovascular or respiratory diseases.

Given that abdominal obesity has been associated in recent studies with a higher risk of respiratory death regardless of BMI, “our study raises potential concerns about how the possible impact of the increase in [waist circumference] reported in the United States and, to a lesser extent, in France on future adverse health outcomes should be considered when assigning resources in respiratory care,” the authors wrote.

“Prospective studies are needed to determine the temporal relationship between lung function impairment and metabolic syndrome, including abdominal adiposity in particular,” they said.

Mechanistic studies are warranted to clarify the underlying physiopathological pathways, the investigators added.

The authors of the study and the editorial reported having no relevant financial conflicts of interest.

The consequences of mild traumatic brain injury are often anything but mild. Recent studies linking concussion to long-term neurologic deficits suggest that, for some individuals, the characteristic transient brain dysfunction and acute symptom resolution represent the beginning of potentially irreversible structural and functional brain alterations.

“Traumatic brain injury occurs as a spectrum disorder. The term 'mild' describes only the initial insult relative to the degree of neurological severity. There may be no correlation with the degree of short- or long-term impairment or functional disability,” said Dr. Nathan Zasler of the University of Virginia, Charlottesville, and medical director of the Concussion Care Centre of Virginia in Glen Allen.

By definition, mild traumatic brain injury (mTBI) results from direct trauma to the head or from an acceleration/deceleration stress to the brain. Such an injury poses a risk for short-term symptoms including headache and difficulty with balance, thinking, concentrating, and sleeping, and may lead to long-term symptoms categorized as postconcussive syndrome, according to the National Institute of Neurological Disorders and Stroke.

Investigators at the University of Illinois at Urbana-Champaign showed that college athletes with a history of sports-related concussion continue to have diminished brain function for a number of years after their injuries (J. Neurotrauma 2009 March [doi:10.1089/neu.2008–0766]). Specifically, “we were able to show that while our group of club and intercollegiate athletes performed normally on standard clinical neurocognitive assessment, they had suppressed brain functioning at an average 31/2 years post injury, including a decrease in attention allocation to things going on in their environment,” lead investigator Steven Broglio, Ph.D., said in an interview. The findings provide further evidence that concussion should not be considered a transient injury associated with short-lived neurologic impairment, he noted.

The authors of a widely reported Canadian case control study reached a similar conclusion. The study compared the neurocognitive status of currently healthy former university-level hockey and football players aged 50–65 years who had sustained a single concussion more than 30 years ago with that of former athletes with no concussion history. Electrophysiologic and neuropsychological tests indicated that individuals with a history of concussion had memory and attention problems along with slower reaction times relative to those of the controls (Brain 2009 Jan. 28 [doi: 10.1093/brain/awn347]).

At the more extreme end of the damage spectrum, biopsies of the brains of six former NFL players between the ages of 25 and 50 who had experienced multiple concussions during their careers revealed evidence of chronic traumatic encephalopathy, according to investigators at Boston University's Center for the Study of Traumatic Encephalopathy (CSTE). All six players had had emotional and behavioral problems such as drug abuse, and two committed suicide, said Dr. Ann C. McKee, lead investigator and CSTE codirector.

Mounting evidence of long-term effects of mTBI in athletes has led to growing concerns about the frequency of concussions among U.S. soldiers in Iraq and Afghanistan. An anonymous survey of more than 2,500 active duty and reserve soldiers conducted 3–4 months after a year-long tour of duty in Iraq showed that mTBI, when associated with a loss of consciousness, led to an increase in posttraumatic stress syndrome, relative to soldiers who had sustained other types of injuries or no injuries (N. Engl. J. Med. 2008;358:453–63).

Considering the large number of U.S. combat soldiers at risk for mTBI, the Department of Defense has mandated that all deploying troops undergo a cognitive functional assessment to serve as a baseline measure for comparison in case of later mTBI.

According to the Centers for Disease Control and Prevention, an estimated 5%–15% of individuals in the general population who sustain an mTBI have long-term deficits of some sort, although actual numbers are difficult to ascertain. “Not all people who sustain a mild brain injury recognize some of the later cognitive and behavioral impairments as related to the injury, and many don't seek medical treatment,” Dr. Zasler said. “This is why [mTBI] is sometimes called an invisible injury—people can look fine on the outside, but they may not be behaving fine, thinking fine, sleeping fine.”

Still, he added, most patients with single mTBIs recover relatively soon if they don't have comorbidities, or psychiatric or neurological histories that increase their vulnerability.

New evidence confirms suspicions that post mTBI problems are substantially underreported. Karen Hux, Ph.D., of the University of Nebraska-Lincoln and her colleagues evaluated a TBI screening procedure at vocational rehabilitation centers, domestic abuse and homeless shelters, and mental health centers. Of 1,999 screening protocols administered by professionals from four service agencies over a 6-month period, 531 were positive for a possible mTBI of sufficient severity to affect quality of life (Brain Inj. 2009;23:8–14).

The only objective method for detecting or confirming mTBI is specialized medical imaging. “CT and MRI scans of patients suffering persistent cognitive impairment as a result of mild traumatic brain injury usually look totally normal. When you look at the raw images, you can't really see anything abnormal. What you need to do is look at the images quantitatively,” said Dr. Michael Lipton of the department of radiology at Albert Einstein College of Medicine in New York. He and his colleagues use MRI-based diffusion tensor imaging (DTI) to map the location, orientation, and anisotropy of the brain's white matter tracts. “We analyze each and every voxel of the brain looking for statistically significant differences between [mTBI] patients and healthy controls.”

The ability to detect subtle neuronal injury has important clinical implications for the management of mTBI, Dr. Lipton said. Identifying individuals with mild injury would allow the use and evaluation of candidate therapies designed to arrest the progression of damage.

Although the clinical utility of DTI has been established and the technology is being used at many academic centers for clinical measurement, “with the current state of the art, it requires specialized expertise to be able to extract information from the images,” he said.

The early identification and management of mTBI should get a boost from evidence-based clinical guidelines by the American College of Emergency Physicians and the CDC. Although the 2008 guidelines are written primarily for emergency physicians, “many patients with mild traumatic brain injury seek care from other practitioners such as internists,” said Dr. Andy Jagoda of Mount Sinai School of Medicine in New York, and chair of the guideline writing panel. For that reason, all clinicians should be made aware of them.

Diffusion tensor imaging reveals subtle neuronal damage (red) in mild traumatic brain injury. Images courtesy Dr. Michael Lipton

The consequences of mild traumatic brain injury are often anything but mild. Recent studies linking concussion to long-term neurologic deficits suggest that, for some individuals, the characteristic transient brain dysfunction and acute symptom resolution represent the beginning of potentially irreversible structural and functional brain alterations.

“Traumatic brain injury occurs as a spectrum disorder. The term 'mild' describes only the initial insult relative to the degree of neurological severity. There may be no correlation with the degree of short- or long-term impairment or functional disability,” said Dr. Nathan Zasler of the University of Virginia, Charlottesville, and medical director of the Concussion Care Centre of Virginia in Glen Allen.

By definition, mild traumatic brain injury (mTBI) results from direct trauma to the head or from an acceleration/deceleration stress to the brain. Such an injury poses a risk for short-term symptoms including headache and difficulty with balance, thinking, concentrating, and sleeping, and may lead to long-term symptoms categorized as postconcussive syndrome, according to the National Institute of Neurological Disorders and Stroke.

Investigators at the University of Illinois at Urbana-Champaign showed that college athletes with a history of sports-related concussion continue to have diminished brain function for a number of years after their injuries (J. Neurotrauma 2009 March [doi:10.1089/neu.2008–0766]). Specifically, “we were able to show that while our group of club and intercollegiate athletes performed normally on standard clinical neurocognitive assessment, they had suppressed brain functioning at an average 31/2 years post injury, including a decrease in attention allocation to things going on in their environment,” lead investigator Steven Broglio, Ph.D., said in an interview. The findings provide further evidence that concussion should not be considered a transient injury associated with short-lived neurologic impairment, he noted.

The authors of a widely reported Canadian case control study reached a similar conclusion. The study compared the neurocognitive status of currently healthy former university-level hockey and football players aged 50–65 years who had sustained a single concussion more than 30 years ago with that of former athletes with no concussion history. Electrophysiologic and neuropsychological tests indicated that individuals with a history of concussion had memory and attention problems along with slower reaction times relative to those of the controls (Brain 2009 Jan. 28 [doi: 10.1093/brain/awn347]).

At the more extreme end of the damage spectrum, biopsies of the brains of six former NFL players between the ages of 25 and 50 who had experienced multiple concussions during their careers revealed evidence of chronic traumatic encephalopathy, according to investigators at Boston University's Center for the Study of Traumatic Encephalopathy (CSTE). All six players had had emotional and behavioral problems such as drug abuse, and two committed suicide, said Dr. Ann C. McKee, lead investigator and CSTE codirector.

Mounting evidence of long-term effects of mTBI in athletes has led to growing concerns about the frequency of concussions among U.S. soldiers in Iraq and Afghanistan. An anonymous survey of more than 2,500 active duty and reserve soldiers conducted 3–4 months after a year-long tour of duty in Iraq showed that mTBI, when associated with a loss of consciousness, led to an increase in posttraumatic stress syndrome, relative to soldiers who had sustained other types of injuries or no injuries (N. Engl. J. Med. 2008;358:453–63).

Considering the large number of U.S. combat soldiers at risk for mTBI, the Department of Defense has mandated that all deploying troops undergo a cognitive functional assessment to serve as a baseline measure for comparison in case of later mTBI.

According to the Centers for Disease Control and Prevention, an estimated 5%–15% of individuals in the general population who sustain an mTBI have long-term deficits of some sort, although actual numbers are difficult to ascertain. “Not all people who sustain a mild brain injury recognize some of the later cognitive and behavioral impairments as related to the injury, and many don't seek medical treatment,” Dr. Zasler said. “This is why [mTBI] is sometimes called an invisible injury—people can look fine on the outside, but they may not be behaving fine, thinking fine, sleeping fine.”

Still, he added, most patients with single mTBIs recover relatively soon if they don't have comorbidities, or psychiatric or neurological histories that increase their vulnerability.

New evidence confirms suspicions that post mTBI problems are substantially underreported. Karen Hux, Ph.D., of the University of Nebraska-Lincoln and her colleagues evaluated a TBI screening procedure at vocational rehabilitation centers, domestic abuse and homeless shelters, and mental health centers. Of 1,999 screening protocols administered by professionals from four service agencies over a 6-month period, 531 were positive for a possible mTBI of sufficient severity to affect quality of life (Brain Inj. 2009;23:8–14).

The only objective method for detecting or confirming mTBI is specialized medical imaging. “CT and MRI scans of patients suffering persistent cognitive impairment as a result of mild traumatic brain injury usually look totally normal. When you look at the raw images, you can't really see anything abnormal. What you need to do is look at the images quantitatively,” said Dr. Michael Lipton of the department of radiology at Albert Einstein College of Medicine in New York. He and his colleagues use MRI-based diffusion tensor imaging (DTI) to map the location, orientation, and anisotropy of the brain's white matter tracts. “We analyze each and every voxel of the brain looking for statistically significant differences between [mTBI] patients and healthy controls.”

The ability to detect subtle neuronal injury has important clinical implications for the management of mTBI, Dr. Lipton said. Identifying individuals with mild injury would allow the use and evaluation of candidate therapies designed to arrest the progression of damage.

Although the clinical utility of DTI has been established and the technology is being used at many academic centers for clinical measurement, “with the current state of the art, it requires specialized expertise to be able to extract information from the images,” he said.

The early identification and management of mTBI should get a boost from evidence-based clinical guidelines by the American College of Emergency Physicians and the CDC. Although the 2008 guidelines are written primarily for emergency physicians, “many patients with mild traumatic brain injury seek care from other practitioners such as internists,” said Dr. Andy Jagoda of Mount Sinai School of Medicine in New York, and chair of the guideline writing panel. For that reason, all clinicians should be made aware of them.

Diffusion tensor imaging reveals subtle neuronal damage (red) in mild traumatic brain injury. Images courtesy Dr. Michael Lipton

The consequences of mild traumatic brain injury are often anything but mild. Recent studies linking concussion to long-term neurologic deficits suggest that, for some individuals, the characteristic transient brain dysfunction and acute symptom resolution represent the beginning of potentially irreversible structural and functional brain alterations.

“Traumatic brain injury occurs as a spectrum disorder. The term 'mild' describes only the initial insult relative to the degree of neurological severity. There may be no correlation with the degree of short- or long-term impairment or functional disability,” said Dr. Nathan Zasler of the University of Virginia, Charlottesville, and medical director of the Concussion Care Centre of Virginia in Glen Allen.

By definition, mild traumatic brain injury (mTBI) results from direct trauma to the head or from an acceleration/deceleration stress to the brain. Such an injury poses a risk for short-term symptoms including headache and difficulty with balance, thinking, concentrating, and sleeping, and may lead to long-term symptoms categorized as postconcussive syndrome, according to the National Institute of Neurological Disorders and Stroke.

Investigators at the University of Illinois at Urbana-Champaign showed that college athletes with a history of sports-related concussion continue to have diminished brain function for a number of years after their injuries (J. Neurotrauma 2009 March [doi:10.1089/neu.2008–0766]). Specifically, “we were able to show that while our group of club and intercollegiate athletes performed normally on standard clinical neurocognitive assessment, they had suppressed brain functioning at an average 31/2 years post injury, including a decrease in attention allocation to things going on in their environment,” lead investigator Steven Broglio, Ph.D., said in an interview. The findings provide further evidence that concussion should not be considered a transient injury associated with short-lived neurologic impairment, he noted.

The authors of a widely reported Canadian case control study reached a similar conclusion. The study compared the neurocognitive status of currently healthy former university-level hockey and football players aged 50–65 years who had sustained a single concussion more than 30 years ago with that of former athletes with no concussion history. Electrophysiologic and neuropsychological tests indicated that individuals with a history of concussion had memory and attention problems along with slower reaction times relative to those of the controls (Brain 2009 Jan. 28 [doi: 10.1093/brain/awn347]).

At the more extreme end of the damage spectrum, biopsies of the brains of six former NFL players between the ages of 25 and 50 who had experienced multiple concussions during their careers revealed evidence of chronic traumatic encephalopathy, according to investigators at Boston University's Center for the Study of Traumatic Encephalopathy (CSTE). All six players had had emotional and behavioral problems such as drug abuse, and two committed suicide, said Dr. Ann C. McKee, lead investigator and CSTE codirector.

Mounting evidence of long-term effects of mTBI in athletes has led to growing concerns about the frequency of concussions among U.S. soldiers in Iraq and Afghanistan. An anonymous survey of more than 2,500 active duty and reserve soldiers conducted 3–4 months after a year-long tour of duty in Iraq showed that mTBI, when associated with a loss of consciousness, led to an increase in posttraumatic stress syndrome, relative to soldiers who had sustained other types of injuries or no injuries (N. Engl. J. Med. 2008;358:453–63).

Considering the large number of U.S. combat soldiers at risk for mTBI, the Department of Defense has mandated that all deploying troops undergo a cognitive functional assessment to serve as a baseline measure for comparison in case of later mTBI.

According to the Centers for Disease Control and Prevention, an estimated 5%–15% of individuals in the general population who sustain an mTBI have long-term deficits of some sort, although actual numbers are difficult to ascertain. “Not all people who sustain a mild brain injury recognize some of the later cognitive and behavioral impairments as related to the injury, and many don't seek medical treatment,” Dr. Zasler said. “This is why [mTBI] is sometimes called an invisible injury—people can look fine on the outside, but they may not be behaving fine, thinking fine, sleeping fine.”

Still, he added, most patients with single mTBIs recover relatively soon if they don't have comorbidities, or psychiatric or neurological histories that increase their vulnerability.

New evidence confirms suspicions that post mTBI problems are substantially underreported. Karen Hux, Ph.D., of the University of Nebraska-Lincoln and her colleagues evaluated a TBI screening procedure at vocational rehabilitation centers, domestic abuse and homeless shelters, and mental health centers. Of 1,999 screening protocols administered by professionals from four service agencies over a 6-month period, 531 were positive for a possible mTBI of sufficient severity to affect quality of life (Brain Inj. 2009;23:8–14).

The only objective method for detecting or confirming mTBI is specialized medical imaging. “CT and MRI scans of patients suffering persistent cognitive impairment as a result of mild traumatic brain injury usually look totally normal. When you look at the raw images, you can't really see anything abnormal. What you need to do is look at the images quantitatively,” said Dr. Michael Lipton of the department of radiology at Albert Einstein College of Medicine in New York. He and his colleagues use MRI-based diffusion tensor imaging (DTI) to map the location, orientation, and anisotropy of the brain's white matter tracts. “We analyze each and every voxel of the brain looking for statistically significant differences between [mTBI] patients and healthy controls.”

The ability to detect subtle neuronal injury has important clinical implications for the management of mTBI, Dr. Lipton said. Identifying individuals with mild injury would allow the use and evaluation of candidate therapies designed to arrest the progression of damage.

Although the clinical utility of DTI has been established and the technology is being used at many academic centers for clinical measurement, “with the current state of the art, it requires specialized expertise to be able to extract information from the images,” he said.

The early identification and management of mTBI should get a boost from evidence-based clinical guidelines by the American College of Emergency Physicians and the CDC. Although the 2008 guidelines are written primarily for emergency physicians, “many patients with mild traumatic brain injury seek care from other practitioners such as internists,” said Dr. Andy Jagoda of Mount Sinai School of Medicine in New York, and chair of the guideline writing panel. For that reason, all clinicians should be made aware of them.

Diffusion tensor imaging reveals subtle neuronal damage (red) in mild traumatic brain injury. Images courtesy Dr. Michael Lipton

MONTREAL — Mounting evidence suggests a substantial survival benefit associated with immediate initiation of antiretroviral therapy in adults with HIV, compared with deferred treatment, investigators reported at the Conference on Retroviruses and Opportunistic Infections.

Although treatment guidelines recommend starting antiretroviral therapy when CD4 T cells fall below 350 cells/mm

In one of the two studies, the increased risk of death associated with treatment deferral was about 40%, according to lead investigator Dr. Mari Kitahata of the University of Washington, Seattle.

As part of the North American AIDS Cohort Collaboration on Research and Design observational study, Dr. Kitahata and colleagues compared the outcomes of 2,620 HIV-positive adults who began highly active antiretroviral therapy (HAART) when their CD4 cell counts were higher than 500 cells/mm

The relative risk of death among patients in the deferral group was 1.4, compared with the early initiators, Dr. Kitahata said.

Data from the North American and European When to Start Consortium also showed a survival advantage for earlier treatment. The findings of the retrospective examination of 15 cohort studies indicated that HIV-positive adults whose CD4 cell count was between 251 and 350 cells/mm

All of the 21,247 patients included in the analysis began treatment for the first time when their CD4 cell count fell below 550 cells/mm

Although starting therapy with a CD4 cell count above 350 cells/mm

Although the findings of both studies suggest that the current treatment guidelines might be too conservative, neither study can offer a definitive answer, Dr. Sterne said at a press briefing.

Dr. Kitahata and Dr. Sterne had no financial disclosures to report.

MONTREAL — Mounting evidence suggests a substantial survival benefit associated with immediate initiation of antiretroviral therapy in adults with HIV, compared with deferred treatment, investigators reported at the Conference on Retroviruses and Opportunistic Infections.

Although treatment guidelines recommend starting antiretroviral therapy when CD4 T cells fall below 350 cells/mm

In one of the two studies, the increased risk of death associated with treatment deferral was about 40%, according to lead investigator Dr. Mari Kitahata of the University of Washington, Seattle.

As part of the North American AIDS Cohort Collaboration on Research and Design observational study, Dr. Kitahata and colleagues compared the outcomes of 2,620 HIV-positive adults who began highly active antiretroviral therapy (HAART) when their CD4 cell counts were higher than 500 cells/mm

The relative risk of death among patients in the deferral group was 1.4, compared with the early initiators, Dr. Kitahata said.

Data from the North American and European When to Start Consortium also showed a survival advantage for earlier treatment. The findings of the retrospective examination of 15 cohort studies indicated that HIV-positive adults whose CD4 cell count was between 251 and 350 cells/mm

All of the 21,247 patients included in the analysis began treatment for the first time when their CD4 cell count fell below 550 cells/mm

Although starting therapy with a CD4 cell count above 350 cells/mm

Although the findings of both studies suggest that the current treatment guidelines might be too conservative, neither study can offer a definitive answer, Dr. Sterne said at a press briefing.

Dr. Kitahata and Dr. Sterne had no financial disclosures to report.

MONTREAL — Mounting evidence suggests a substantial survival benefit associated with immediate initiation of antiretroviral therapy in adults with HIV, compared with deferred treatment, investigators reported at the Conference on Retroviruses and Opportunistic Infections.

Although treatment guidelines recommend starting antiretroviral therapy when CD4 T cells fall below 350 cells/mm

In one of the two studies, the increased risk of death associated with treatment deferral was about 40%, according to lead investigator Dr. Mari Kitahata of the University of Washington, Seattle.

As part of the North American AIDS Cohort Collaboration on Research and Design observational study, Dr. Kitahata and colleagues compared the outcomes of 2,620 HIV-positive adults who began highly active antiretroviral therapy (HAART) when their CD4 cell counts were higher than 500 cells/mm

The relative risk of death among patients in the deferral group was 1.4, compared with the early initiators, Dr. Kitahata said.

Data from the North American and European When to Start Consortium also showed a survival advantage for earlier treatment. The findings of the retrospective examination of 15 cohort studies indicated that HIV-positive adults whose CD4 cell count was between 251 and 350 cells/mm

All of the 21,247 patients included in the analysis began treatment for the first time when their CD4 cell count fell below 550 cells/mm

Although starting therapy with a CD4 cell count above 350 cells/mm

Although the findings of both studies suggest that the current treatment guidelines might be too conservative, neither study can offer a definitive answer, Dr. Sterne said at a press briefing.

Dr. Kitahata and Dr. Sterne had no financial disclosures to report.

MONTREAL — Although the rates of AIDS-defining cancers have declined significantly among people with HIV infection since the advent of antiretroviral therapy, the rates of non-AIDS-defining cancers—particularly those associated with an underlying infectious pathogen—continue to be significantly higher than those observed in the HIV-negative population.

At the 16th Conference on Retroviruses and Opportunistic Infections, Michael J. Silverberg, Ph.D., of Kaiser Permanente in Oakland, Calif., presented findings from a retrospective cohort study comparing the incidence of non-AIDS-defining cancers (cancers other than Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer) in HIV-positive and HIV-negative persons during 1996–2006. With the use of data from the managed health program, Dr. Silverberg and colleagues identified 18,890 HIV-positive patients and 189,804 age-, sex-, and year-matched HIV-negative patients and followed the cohort members from first enrollment after Jan. 1, 1996.

From Surveillance, Epidemiology, and End Results program-based Kaiser Permanent cancer registries, the investigators identified incident, non-AIDS-defining cancers in the study population and grouped the cancers as infection related (anal, head and neck, liver, Hodgkins lymphoma, and others) or infection unrelated. In the HIV-positive population, there were 482 reports of non-AIDS-defining cancers, including 220 that were infection related and 269 that were not related to infection; seven patients had both. In comparison, 3,065 non-AIDS-defining cancers were identified in the HIV-negative population, including 398 infection related and 2,698 infection unrelated (31 had both), Dr. Silverberg said.

Calculated per 10,000 person-years, the rate of infection-related, non-AIDS-defining cancers was nearly seven times greater among the HIV-positive group, at 29.7, compared with 4.4 in the HIV-negative group, Dr. Silverberg stated, noting also that the age- and sex-adjusted relative risks “did not change over time.” Specifically, the relative risks for the periods of 1996–1999, 2000–2003, and 2004–2006, were 6.4, 7.6, and 6.2, respectively. In terms of specific infection-related cancers, the significant relative risks for anal cancer, Hodgkin's lymphoma, head and neck cancer, and gynecologic cancer were 81.4, 17.4, 2.1, and 2.9, respectively, he said.

Despite the increased risk, compared with HIV-negative individuals, “the risk of developing an infection-related non-AIDS-defining cancer did drop by approximately 4% [between 1996 and 2006],” Dr. Silverberg said. The risk of anal cancer in particular decreased in the HIV-positive population by about 6% per year, he said. During the same period, the risk of infection-related cancer remained constant among HIV-negative individuals.

With respect to infection-unrelated non-AIDS-defining cancers, the incidence rates per 10,000 person-years were 36.4 and 30.6 for the HIV-positive and HIV-negative groups, respectively, Dr. Silverberg noted. The only significant rate ratio was that observed for the 2004–2006 period, at 1.3, he said. Significant cancer-specific rate ratios were observed for kidney cancer, lung cancer, melanoma, and prostate cancer at 1.8, 1.7, 1.7, and 0.7, respectively.

The study findings may not be generalizable to women because nearly three-quarters of the cancer cases identified through the registry were men who have sex with men, Dr. Silverberg noted. Additionally, because the study data came from a managed care database, the findings may not be generalizable to uninsured persons, he said.

The conference was sponsored by the Foundation for Retrovirology and Human Health and the Centers for Disease Control and Prevention.

Dr. Silverberg reported no potential conflicts of interest.

The cancers were nearly seven times more likely among the HIV-positive group compared with the HIV-negative group. DR. SILVERBERG

MONTREAL — Although the rates of AIDS-defining cancers have declined significantly among people with HIV infection since the advent of antiretroviral therapy, the rates of non-AIDS-defining cancers—particularly those associated with an underlying infectious pathogen—continue to be significantly higher than those observed in the HIV-negative population.

At the 16th Conference on Retroviruses and Opportunistic Infections, Michael J. Silverberg, Ph.D., of Kaiser Permanente in Oakland, Calif., presented findings from a retrospective cohort study comparing the incidence of non-AIDS-defining cancers (cancers other than Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer) in HIV-positive and HIV-negative persons during 1996–2006. With the use of data from the managed health program, Dr. Silverberg and colleagues identified 18,890 HIV-positive patients and 189,804 age-, sex-, and year-matched HIV-negative patients and followed the cohort members from first enrollment after Jan. 1, 1996.

From Surveillance, Epidemiology, and End Results program-based Kaiser Permanent cancer registries, the investigators identified incident, non-AIDS-defining cancers in the study population and grouped the cancers as infection related (anal, head and neck, liver, Hodgkins lymphoma, and others) or infection unrelated. In the HIV-positive population, there were 482 reports of non-AIDS-defining cancers, including 220 that were infection related and 269 that were not related to infection; seven patients had both. In comparison, 3,065 non-AIDS-defining cancers were identified in the HIV-negative population, including 398 infection related and 2,698 infection unrelated (31 had both), Dr. Silverberg said.

Calculated per 10,000 person-years, the rate of infection-related, non-AIDS-defining cancers was nearly seven times greater among the HIV-positive group, at 29.7, compared with 4.4 in the HIV-negative group, Dr. Silverberg stated, noting also that the age- and sex-adjusted relative risks “did not change over time.” Specifically, the relative risks for the periods of 1996–1999, 2000–2003, and 2004–2006, were 6.4, 7.6, and 6.2, respectively. In terms of specific infection-related cancers, the significant relative risks for anal cancer, Hodgkin's lymphoma, head and neck cancer, and gynecologic cancer were 81.4, 17.4, 2.1, and 2.9, respectively, he said.

Despite the increased risk, compared with HIV-negative individuals, “the risk of developing an infection-related non-AIDS-defining cancer did drop by approximately 4% [between 1996 and 2006],” Dr. Silverberg said. The risk of anal cancer in particular decreased in the HIV-positive population by about 6% per year, he said. During the same period, the risk of infection-related cancer remained constant among HIV-negative individuals.

With respect to infection-unrelated non-AIDS-defining cancers, the incidence rates per 10,000 person-years were 36.4 and 30.6 for the HIV-positive and HIV-negative groups, respectively, Dr. Silverberg noted. The only significant rate ratio was that observed for the 2004–2006 period, at 1.3, he said. Significant cancer-specific rate ratios were observed for kidney cancer, lung cancer, melanoma, and prostate cancer at 1.8, 1.7, 1.7, and 0.7, respectively.

The study findings may not be generalizable to women because nearly three-quarters of the cancer cases identified through the registry were men who have sex with men, Dr. Silverberg noted. Additionally, because the study data came from a managed care database, the findings may not be generalizable to uninsured persons, he said.

The conference was sponsored by the Foundation for Retrovirology and Human Health and the Centers for Disease Control and Prevention.

Dr. Silverberg reported no potential conflicts of interest.

The cancers were nearly seven times more likely among the HIV-positive group compared with the HIV-negative group. DR. SILVERBERG

MONTREAL — Although the rates of AIDS-defining cancers have declined significantly among people with HIV infection since the advent of antiretroviral therapy, the rates of non-AIDS-defining cancers—particularly those associated with an underlying infectious pathogen—continue to be significantly higher than those observed in the HIV-negative population.

At the 16th Conference on Retroviruses and Opportunistic Infections, Michael J. Silverberg, Ph.D., of Kaiser Permanente in Oakland, Calif., presented findings from a retrospective cohort study comparing the incidence of non-AIDS-defining cancers (cancers other than Kaposi's sarcoma, non-Hodgkin's lymphoma, and cervical cancer) in HIV-positive and HIV-negative persons during 1996–2006. With the use of data from the managed health program, Dr. Silverberg and colleagues identified 18,890 HIV-positive patients and 189,804 age-, sex-, and year-matched HIV-negative patients and followed the cohort members from first enrollment after Jan. 1, 1996.

From Surveillance, Epidemiology, and End Results program-based Kaiser Permanent cancer registries, the investigators identified incident, non-AIDS-defining cancers in the study population and grouped the cancers as infection related (anal, head and neck, liver, Hodgkins lymphoma, and others) or infection unrelated. In the HIV-positive population, there were 482 reports of non-AIDS-defining cancers, including 220 that were infection related and 269 that were not related to infection; seven patients had both. In comparison, 3,065 non-AIDS-defining cancers were identified in the HIV-negative population, including 398 infection related and 2,698 infection unrelated (31 had both), Dr. Silverberg said.

Calculated per 10,000 person-years, the rate of infection-related, non-AIDS-defining cancers was nearly seven times greater among the HIV-positive group, at 29.7, compared with 4.4 in the HIV-negative group, Dr. Silverberg stated, noting also that the age- and sex-adjusted relative risks “did not change over time.” Specifically, the relative risks for the periods of 1996–1999, 2000–2003, and 2004–2006, were 6.4, 7.6, and 6.2, respectively. In terms of specific infection-related cancers, the significant relative risks for anal cancer, Hodgkin's lymphoma, head and neck cancer, and gynecologic cancer were 81.4, 17.4, 2.1, and 2.9, respectively, he said.

Despite the increased risk, compared with HIV-negative individuals, “the risk of developing an infection-related non-AIDS-defining cancer did drop by approximately 4% [between 1996 and 2006],” Dr. Silverberg said. The risk of anal cancer in particular decreased in the HIV-positive population by about 6% per year, he said. During the same period, the risk of infection-related cancer remained constant among HIV-negative individuals.

With respect to infection-unrelated non-AIDS-defining cancers, the incidence rates per 10,000 person-years were 36.4 and 30.6 for the HIV-positive and HIV-negative groups, respectively, Dr. Silverberg noted. The only significant rate ratio was that observed for the 2004–2006 period, at 1.3, he said. Significant cancer-specific rate ratios were observed for kidney cancer, lung cancer, melanoma, and prostate cancer at 1.8, 1.7, 1.7, and 0.7, respectively.

The study findings may not be generalizable to women because nearly three-quarters of the cancer cases identified through the registry were men who have sex with men, Dr. Silverberg noted. Additionally, because the study data came from a managed care database, the findings may not be generalizable to uninsured persons, he said.

The conference was sponsored by the Foundation for Retrovirology and Human Health and the Centers for Disease Control and Prevention.

Dr. Silverberg reported no potential conflicts of interest.

The cancers were nearly seven times more likely among the HIV-positive group compared with the HIV-negative group. DR. SILVERBERG

BOSTON — Conjunctivitis: It's red, it's itchy, it's crusty, but it is not—repeat NOT—cause for automatic exclusion from day care or school, according to the latest edition of the American Academy of Pediatrics' "Managing Infectious Diseases in Child Care and Schools."

The rationale behind this seemingly revolutionary recommendation is the fact that neither treatment nor exclusion of children with conjunctivitis from group settings reduces the spread of infection, Dr. Laura A. Jana said at the annual meeting of the American Academy of Pediatrics.

"Multiple studies have shown that most viruses are spread by children who seem well, which means that exposure happens before the school or day care facility can make the first phone call for the child to be picked up," said Dr. Jana, a pediatrician and owner of a child care facility in Omaha, Neb.

So while conventional wisdom says that automatically excluding kids with conjunctivitis, fever, and stomachaches will prevent the spread of these infections, "the evidence doesn't back this up," she said, noting that "hand and surface hygiene continue to be the best way to reduce infections in group care."

Unfortunately, despite the existence of evidence-based national exclusion guidelines published in 2002 by the AAP and the American Public Health Association and other organizations, "conventional wisdom" often trumps evidence in exclusion decisions.

"Many children are excluded from school and child care when they should not be and some children who meet guideline exclusion criteria remain in school and child care, possibly exposing other children to illness and diverting caregivers' attention from other, healthy children while tending to sick children," according to Dr. Jana. Too often, children with nonbacterial conjunctivitis, mild stomachaches, runny noses, and ringworm are being sent home unnecessarily.

The confusion regarding exclusion is understandable, said Dr. Jana. Unlike the best-practice guidelines issued in 2002 by the AAP and others, state guidelines for exclusion from child care or school lack detail, are not based on medical evidence, and vary considerably by state. "Most states do not require center and school policies to follow national guidelines, and individual exclusion policies must only comply with state licensing, which means children are often excluded for harmless conditions," she said. The consequences of inappropriate exclusion policies and practices, she added, include excess health care visits, antibiotic-seeking behavior, and lost work and school time.

The one exclusion criterion from the national guidelines that is excluded most frequently, according to Dr. Jana, is the directive that a child should be excluded if the illness prevents him or her from participating comfortably in activities. "This child should really be at home," she said. "Additionally, a child should be excluded from school or day care if the illness results in greater care than the staff can provide," she noted, or if the illness poses a risk of spreading a harmful disease to others. (See box.)

The common cold, for example, does not warrant exclusion, "unless the child is too uncomfortable to participate in routine daily activities," Dr. Jana said.

The updated "Managing Infectious Diseases in Child Care and Schools" (Elk Grove Village, Ill.: American Academy of Pediatrics, 2008), also recommends against exclusion for the following conditions that often incite red flags, according to Dr. Jana:

▸ Hand, foot, and mouth disease. "Children should not be excluded unless they have sores in their mouth with drooling or if the rash is associated with fever or behavior change," Dr. Jana explained.

▸ Fifth disease. Because there is little virus present when the rash appears.

▸ Draining skin infection, including methicillin-resistant Staphylococcus aureus (MRSA). "Because of the media attention surrounding MRSA, there's a lot of anxiety about this, but the reality is, these children should be excluded only if the infection is accompanied by fever, pain, or behavior change," said Dr. Jana. "There is no need for the caregiver to request a culture, because it won't affect how the infection will be handled. Some kids without symptoms have MRSA, and there is no good way to eradicate the germ yet."

▸ Diarrhea. According to the revised guidelines, diapered children with diarrhea may remain in care if the diarrhea is contained in the diaper and the child has no more than two stools above normal. Children who are able to use the toilet may remain in care with good hand washing, as long as they don't have accidents. "Exclusion is appropriate for children with blood in their stool not explained by medication, hard stool, or diet," she said.

▸ Vomiting. The guidelines recommend exclusion for a child who has had two or more episodes of vomiting in the previous 24 hours and continuing exclusion until the vomiting resolves or it is determined the cause is not contagious.

▸ Fever. "Children with fever should not be excluded automatically, unless the fever is accompanied by behavior change or other signs or symptoms of illness," said Dr. Jana. The exception to this is children younger than 4 months old with unexplained fever.

▸ Respiratory illness. Most respiratory illnesses do not require exclusion; however, a child with persistent coughing or trouble breathing should be evaluated for pneumonia, asthma, or serious respiratory infection, such as whooping cough, Dr. Jana noted.

▸ Earache, no fever. "This child should be excluded if he or she requires more care than the staff can reasonably provide," said Dr. Jana.

▸ Lice. "Lice are a nuisance, but they're not a health hazard," she said. "Children with lice should be excluded, but they don't have to be sent home right away. It can wait until the end of the day."

Revised 'When to Exclude' Criteria

With the exception of the noted updates, most of the exclusion criteria outlined in the revised "Managing Infectious Diseases in Child Care and Schools" are consistent with the national illness exclusion guidelines published in 2002. These include:

▸ Tuberculosis, until an appropriate health care provider or health official certifies that the child is in appropriate therapy and can attend care.

▸ Impetigo, until 24 hours after treatment has been initiated.

▸ Chickenpox until all sores have dried and crusted (usually 6 days).

▸ Mumps, until 9 days after an onset of parotid gland swelling.

▸ Hepatitis A virus, until 1 week after an onset of illness or jaundice or as directed by the health department.

▸ Measles, until 4 days after rash onset.

▸ Rubella, until 6 days after rash onset.

▸ Fever, when accompanied by behavior changes or other symptoms.

▸ Diarrhea.

▸ Blood in the stool not explained by dietary change, medication, or hard stool.

▸ Vomiting two or more times in a 24-hour period.

▸ Body rash with fever.

▸ Sore throat with fever and swollen glands or mouth sores with drooling.

▸ Severe coughing with the child getting red or blue in the face or making a high-pitched whooping sound after coughing.

▸ Persistent abdominal pain (more than 2 hours) or intermittent pain with other signs and symptoms.

▸ Signs of severe illness such as irritability, unusual tiredness, or neediness that compromises caregivers' ability to care for other children.

▸ Uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.

BOSTON — Conjunctivitis: It's red, it's itchy, it's crusty, but it is not—repeat NOT—cause for automatic exclusion from day care or school, according to the latest edition of the American Academy of Pediatrics' "Managing Infectious Diseases in Child Care and Schools."

The rationale behind this seemingly revolutionary recommendation is the fact that neither treatment nor exclusion of children with conjunctivitis from group settings reduces the spread of infection, Dr. Laura A. Jana said at the annual meeting of the American Academy of Pediatrics.

"Multiple studies have shown that most viruses are spread by children who seem well, which means that exposure happens before the school or day care facility can make the first phone call for the child to be picked up," said Dr. Jana, a pediatrician and owner of a child care facility in Omaha, Neb.

So while conventional wisdom says that automatically excluding kids with conjunctivitis, fever, and stomachaches will prevent the spread of these infections, "the evidence doesn't back this up," she said, noting that "hand and surface hygiene continue to be the best way to reduce infections in group care."

Unfortunately, despite the existence of evidence-based national exclusion guidelines published in 2002 by the AAP and the American Public Health Association and other organizations, "conventional wisdom" often trumps evidence in exclusion decisions.

"Many children are excluded from school and child care when they should not be and some children who meet guideline exclusion criteria remain in school and child care, possibly exposing other children to illness and diverting caregivers' attention from other, healthy children while tending to sick children," according to Dr. Jana. Too often, children with nonbacterial conjunctivitis, mild stomachaches, runny noses, and ringworm are being sent home unnecessarily.

The confusion regarding exclusion is understandable, said Dr. Jana. Unlike the best-practice guidelines issued in 2002 by the AAP and others, state guidelines for exclusion from child care or school lack detail, are not based on medical evidence, and vary considerably by state. "Most states do not require center and school policies to follow national guidelines, and individual exclusion policies must only comply with state licensing, which means children are often excluded for harmless conditions," she said. The consequences of inappropriate exclusion policies and practices, she added, include excess health care visits, antibiotic-seeking behavior, and lost work and school time.

The one exclusion criterion from the national guidelines that is excluded most frequently, according to Dr. Jana, is the directive that a child should be excluded if the illness prevents him or her from participating comfortably in activities. "This child should really be at home," she said. "Additionally, a child should be excluded from school or day care if the illness results in greater care than the staff can provide," she noted, or if the illness poses a risk of spreading a harmful disease to others. (See box.)

The common cold, for example, does not warrant exclusion, "unless the child is too uncomfortable to participate in routine daily activities," Dr. Jana said.

The updated "Managing Infectious Diseases in Child Care and Schools" (Elk Grove Village, Ill.: American Academy of Pediatrics, 2008), also recommends against exclusion for the following conditions that often incite red flags, according to Dr. Jana:

▸ Hand, foot, and mouth disease. "Children should not be excluded unless they have sores in their mouth with drooling or if the rash is associated with fever or behavior change," Dr. Jana explained.

▸ Fifth disease. Because there is little virus present when the rash appears.

▸ Draining skin infection, including methicillin-resistant Staphylococcus aureus (MRSA). "Because of the media attention surrounding MRSA, there's a lot of anxiety about this, but the reality is, these children should be excluded only if the infection is accompanied by fever, pain, or behavior change," said Dr. Jana. "There is no need for the caregiver to request a culture, because it won't affect how the infection will be handled. Some kids without symptoms have MRSA, and there is no good way to eradicate the germ yet."

▸ Diarrhea. According to the revised guidelines, diapered children with diarrhea may remain in care if the diarrhea is contained in the diaper and the child has no more than two stools above normal. Children who are able to use the toilet may remain in care with good hand washing, as long as they don't have accidents. "Exclusion is appropriate for children with blood in their stool not explained by medication, hard stool, or diet," she said.

▸ Vomiting. The guidelines recommend exclusion for a child who has had two or more episodes of vomiting in the previous 24 hours and continuing exclusion until the vomiting resolves or it is determined the cause is not contagious.

▸ Fever. "Children with fever should not be excluded automatically, unless the fever is accompanied by behavior change or other signs or symptoms of illness," said Dr. Jana. The exception to this is children younger than 4 months old with unexplained fever.

▸ Respiratory illness. Most respiratory illnesses do not require exclusion; however, a child with persistent coughing or trouble breathing should be evaluated for pneumonia, asthma, or serious respiratory infection, such as whooping cough, Dr. Jana noted.

▸ Earache, no fever. "This child should be excluded if he or she requires more care than the staff can reasonably provide," said Dr. Jana.

▸ Lice. "Lice are a nuisance, but they're not a health hazard," she said. "Children with lice should be excluded, but they don't have to be sent home right away. It can wait until the end of the day."

Revised 'When to Exclude' Criteria

With the exception of the noted updates, most of the exclusion criteria outlined in the revised "Managing Infectious Diseases in Child Care and Schools" are consistent with the national illness exclusion guidelines published in 2002. These include:

▸ Tuberculosis, until an appropriate health care provider or health official certifies that the child is in appropriate therapy and can attend care.

▸ Impetigo, until 24 hours after treatment has been initiated.

▸ Chickenpox until all sores have dried and crusted (usually 6 days).

▸ Mumps, until 9 days after an onset of parotid gland swelling.

▸ Hepatitis A virus, until 1 week after an onset of illness or jaundice or as directed by the health department.

▸ Measles, until 4 days after rash onset.

▸ Rubella, until 6 days after rash onset.

▸ Fever, when accompanied by behavior changes or other symptoms.

▸ Diarrhea.

▸ Blood in the stool not explained by dietary change, medication, or hard stool.

▸ Vomiting two or more times in a 24-hour period.

▸ Body rash with fever.

▸ Sore throat with fever and swollen glands or mouth sores with drooling.

▸ Severe coughing with the child getting red or blue in the face or making a high-pitched whooping sound after coughing.

▸ Persistent abdominal pain (more than 2 hours) or intermittent pain with other signs and symptoms.

▸ Signs of severe illness such as irritability, unusual tiredness, or neediness that compromises caregivers' ability to care for other children.

▸ Uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.

BOSTON — Conjunctivitis: It's red, it's itchy, it's crusty, but it is not—repeat NOT—cause for automatic exclusion from day care or school, according to the latest edition of the American Academy of Pediatrics' "Managing Infectious Diseases in Child Care and Schools."

The rationale behind this seemingly revolutionary recommendation is the fact that neither treatment nor exclusion of children with conjunctivitis from group settings reduces the spread of infection, Dr. Laura A. Jana said at the annual meeting of the American Academy of Pediatrics.

"Multiple studies have shown that most viruses are spread by children who seem well, which means that exposure happens before the school or day care facility can make the first phone call for the child to be picked up," said Dr. Jana, a pediatrician and owner of a child care facility in Omaha, Neb.

So while conventional wisdom says that automatically excluding kids with conjunctivitis, fever, and stomachaches will prevent the spread of these infections, "the evidence doesn't back this up," she said, noting that "hand and surface hygiene continue to be the best way to reduce infections in group care."

Unfortunately, despite the existence of evidence-based national exclusion guidelines published in 2002 by the AAP and the American Public Health Association and other organizations, "conventional wisdom" often trumps evidence in exclusion decisions.

"Many children are excluded from school and child care when they should not be and some children who meet guideline exclusion criteria remain in school and child care, possibly exposing other children to illness and diverting caregivers' attention from other, healthy children while tending to sick children," according to Dr. Jana. Too often, children with nonbacterial conjunctivitis, mild stomachaches, runny noses, and ringworm are being sent home unnecessarily.

The confusion regarding exclusion is understandable, said Dr. Jana. Unlike the best-practice guidelines issued in 2002 by the AAP and others, state guidelines for exclusion from child care or school lack detail, are not based on medical evidence, and vary considerably by state. "Most states do not require center and school policies to follow national guidelines, and individual exclusion policies must only comply with state licensing, which means children are often excluded for harmless conditions," she said. The consequences of inappropriate exclusion policies and practices, she added, include excess health care visits, antibiotic-seeking behavior, and lost work and school time.

The one exclusion criterion from the national guidelines that is excluded most frequently, according to Dr. Jana, is the directive that a child should be excluded if the illness prevents him or her from participating comfortably in activities. "This child should really be at home," she said. "Additionally, a child should be excluded from school or day care if the illness results in greater care than the staff can provide," she noted, or if the illness poses a risk of spreading a harmful disease to others. (See box.)

The common cold, for example, does not warrant exclusion, "unless the child is too uncomfortable to participate in routine daily activities," Dr. Jana said.

The updated "Managing Infectious Diseases in Child Care and Schools" (Elk Grove Village, Ill.: American Academy of Pediatrics, 2008), also recommends against exclusion for the following conditions that often incite red flags, according to Dr. Jana:

▸ Hand, foot, and mouth disease. "Children should not be excluded unless they have sores in their mouth with drooling or if the rash is associated with fever or behavior change," Dr. Jana explained.

▸ Fifth disease. Because there is little virus present when the rash appears.

▸ Draining skin infection, including methicillin-resistant Staphylococcus aureus (MRSA). "Because of the media attention surrounding MRSA, there's a lot of anxiety about this, but the reality is, these children should be excluded only if the infection is accompanied by fever, pain, or behavior change," said Dr. Jana. "There is no need for the caregiver to request a culture, because it won't affect how the infection will be handled. Some kids without symptoms have MRSA, and there is no good way to eradicate the germ yet."

▸ Diarrhea. According to the revised guidelines, diapered children with diarrhea may remain in care if the diarrhea is contained in the diaper and the child has no more than two stools above normal. Children who are able to use the toilet may remain in care with good hand washing, as long as they don't have accidents. "Exclusion is appropriate for children with blood in their stool not explained by medication, hard stool, or diet," she said.

▸ Vomiting. The guidelines recommend exclusion for a child who has had two or more episodes of vomiting in the previous 24 hours and continuing exclusion until the vomiting resolves or it is determined the cause is not contagious.

▸ Fever. "Children with fever should not be excluded automatically, unless the fever is accompanied by behavior change or other signs or symptoms of illness," said Dr. Jana. The exception to this is children younger than 4 months old with unexplained fever.

▸ Respiratory illness. Most respiratory illnesses do not require exclusion; however, a child with persistent coughing or trouble breathing should be evaluated for pneumonia, asthma, or serious respiratory infection, such as whooping cough, Dr. Jana noted.

▸ Earache, no fever. "This child should be excluded if he or she requires more care than the staff can reasonably provide," said Dr. Jana.

▸ Lice. "Lice are a nuisance, but they're not a health hazard," she said. "Children with lice should be excluded, but they don't have to be sent home right away. It can wait until the end of the day."

Revised 'When to Exclude' Criteria

With the exception of the noted updates, most of the exclusion criteria outlined in the revised "Managing Infectious Diseases in Child Care and Schools" are consistent with the national illness exclusion guidelines published in 2002. These include:

▸ Tuberculosis, until an appropriate health care provider or health official certifies that the child is in appropriate therapy and can attend care.

▸ Impetigo, until 24 hours after treatment has been initiated.

▸ Chickenpox until all sores have dried and crusted (usually 6 days).

▸ Mumps, until 9 days after an onset of parotid gland swelling.

▸ Hepatitis A virus, until 1 week after an onset of illness or jaundice or as directed by the health department.

▸ Measles, until 4 days after rash onset.

▸ Rubella, until 6 days after rash onset.

▸ Fever, when accompanied by behavior changes or other symptoms.

▸ Diarrhea.

▸ Blood in the stool not explained by dietary change, medication, or hard stool.

▸ Vomiting two or more times in a 24-hour period.

▸ Body rash with fever.

▸ Sore throat with fever and swollen glands or mouth sores with drooling.

▸ Severe coughing with the child getting red or blue in the face or making a high-pitched whooping sound after coughing.

▸ Persistent abdominal pain (more than 2 hours) or intermittent pain with other signs and symptoms.

▸ Signs of severe illness such as irritability, unusual tiredness, or neediness that compromises caregivers' ability to care for other children.

▸ Uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.

Most pediatric cases of psoriasis are mild and can be managed adequately with combinations of topical medicines, but some cannot, according to Dr. Kelly M. Cordoro.

“The true challenge exists in treating the subset of children who present with severe, rapidly evolving, and debilitating generalized plaque or pustular psoriasis and/or psoriatic arthropathy,” said Dr. Cordoro of the department of dermatology at the University of California, San Francisco.

The management of this subset of patients “requires immediate response with the utilization of systemic medications that are neither well studied nor [Food and Drug Administration] approved for this indication in children,” said Dr. Cordoro, who discussed such medications in a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation in Maui.

Targeted therapies that are aimed at specific components of the inflammatory cascade, such as anti-tumor necrosis factor agents, are widely used in adults with psoriasis and psoriatic arthritis.

Although none of the three TNF antagonists that have received FDA approval for adult psoriasis—etanercept, infliximab, and adalimumab—have been approved for pediatric psoriasis, off-label use of these agents has demonstrated some promise in children with severe disease, Dr. Cordoro said in an interview.

“Etanercept has the most significant published literature, and the fact that the drug has received FDA approval for use in children for other indications [ankylosing spondylitis and psoriatic arthropathy for children aged 2 years and older, and juvenile rheumatoid arthritis in children aged 4 years and older] substantiates recommendations for its use in the pediatric psoriasis population,” she said.

A recent, randomized controlled trial showed that etanercept can safely and effectively reduce disease severity in children and adolescents aged 4–17 years who have moderate to severe plaque psoriasis (N. Engl. J. Med. 2008;358:241–51).

Biologic agents have also been used in the treatment of children with generalized pustular psoriasis, a serious and rare form of the disease that can be fatal.

With respect to drug safety, “critical evaluation of the potential risk of the anti-TNF agents in children with psoriasis is difficult because of the small number of children treated and the short follow-up period,” Dr. Cordoro said.

Even so, “because the known side effect profiles of traditional systemic agents used for severe psoriasis in children [including methotrexate, cyclosporine, and acitretin] are unacceptable, the documented benefits of the TNF inhibitors in children affected by severe, debilitating psoriasis create a therapeutic niche for these agents,” she said.

Dr. Cordoro reported having no conflicts of interest with respect to her presentation.

SDEF and this newspaper are owned by Elsevier.

Off-label use of the three TNF antagonists has demonstrated some promise in children with severe disease. DR. CORDORO

Most pediatric cases of psoriasis are mild and can be managed adequately with combinations of topical medicines, but some cannot, according to Dr. Kelly M. Cordoro.

“The true challenge exists in treating the subset of children who present with severe, rapidly evolving, and debilitating generalized plaque or pustular psoriasis and/or psoriatic arthropathy,” said Dr. Cordoro of the department of dermatology at the University of California, San Francisco.

The management of this subset of patients “requires immediate response with the utilization of systemic medications that are neither well studied nor [Food and Drug Administration] approved for this indication in children,” said Dr. Cordoro, who discussed such medications in a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation in Maui.

Targeted therapies that are aimed at specific components of the inflammatory cascade, such as anti-tumor necrosis factor agents, are widely used in adults with psoriasis and psoriatic arthritis.

Although none of the three TNF antagonists that have received FDA approval for adult psoriasis—etanercept, infliximab, and adalimumab—have been approved for pediatric psoriasis, off-label use of these agents has demonstrated some promise in children with severe disease, Dr. Cordoro said in an interview.

“Etanercept has the most significant published literature, and the fact that the drug has received FDA approval for use in children for other indications [ankylosing spondylitis and psoriatic arthropathy for children aged 2 years and older, and juvenile rheumatoid arthritis in children aged 4 years and older] substantiates recommendations for its use in the pediatric psoriasis population,” she said.

A recent, randomized controlled trial showed that etanercept can safely and effectively reduce disease severity in children and adolescents aged 4–17 years who have moderate to severe plaque psoriasis (N. Engl. J. Med. 2008;358:241–51).

Biologic agents have also been used in the treatment of children with generalized pustular psoriasis, a serious and rare form of the disease that can be fatal.

With respect to drug safety, “critical evaluation of the potential risk of the anti-TNF agents in children with psoriasis is difficult because of the small number of children treated and the short follow-up period,” Dr. Cordoro said.

Even so, “because the known side effect profiles of traditional systemic agents used for severe psoriasis in children [including methotrexate, cyclosporine, and acitretin] are unacceptable, the documented benefits of the TNF inhibitors in children affected by severe, debilitating psoriasis create a therapeutic niche for these agents,” she said.

Dr. Cordoro reported having no conflicts of interest with respect to her presentation.

SDEF and this newspaper are owned by Elsevier.

Off-label use of the three TNF antagonists has demonstrated some promise in children with severe disease. DR. CORDORO

Most pediatric cases of psoriasis are mild and can be managed adequately with combinations of topical medicines, but some cannot, according to Dr. Kelly M. Cordoro.

“The true challenge exists in treating the subset of children who present with severe, rapidly evolving, and debilitating generalized plaque or pustular psoriasis and/or psoriatic arthropathy,” said Dr. Cordoro of the department of dermatology at the University of California, San Francisco.

The management of this subset of patients “requires immediate response with the utilization of systemic medications that are neither well studied nor [Food and Drug Administration] approved for this indication in children,” said Dr. Cordoro, who discussed such medications in a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation in Maui.

Targeted therapies that are aimed at specific components of the inflammatory cascade, such as anti-tumor necrosis factor agents, are widely used in adults with psoriasis and psoriatic arthritis.

Although none of the three TNF antagonists that have received FDA approval for adult psoriasis—etanercept, infliximab, and adalimumab—have been approved for pediatric psoriasis, off-label use of these agents has demonstrated some promise in children with severe disease, Dr. Cordoro said in an interview.

“Etanercept has the most significant published literature, and the fact that the drug has received FDA approval for use in children for other indications [ankylosing spondylitis and psoriatic arthropathy for children aged 2 years and older, and juvenile rheumatoid arthritis in children aged 4 years and older] substantiates recommendations for its use in the pediatric psoriasis population,” she said.

A recent, randomized controlled trial showed that etanercept can safely and effectively reduce disease severity in children and adolescents aged 4–17 years who have moderate to severe plaque psoriasis (N. Engl. J. Med. 2008;358:241–51).

Biologic agents have also been used in the treatment of children with generalized pustular psoriasis, a serious and rare form of the disease that can be fatal.

With respect to drug safety, “critical evaluation of the potential risk of the anti-TNF agents in children with psoriasis is difficult because of the small number of children treated and the short follow-up period,” Dr. Cordoro said.

Even so, “because the known side effect profiles of traditional systemic agents used for severe psoriasis in children [including methotrexate, cyclosporine, and acitretin] are unacceptable, the documented benefits of the TNF inhibitors in children affected by severe, debilitating psoriasis create a therapeutic niche for these agents,” she said.

Dr. Cordoro reported having no conflicts of interest with respect to her presentation.

SDEF and this newspaper are owned by Elsevier.

Off-label use of the three TNF antagonists has demonstrated some promise in children with severe disease. DR. CORDORO