Diana Mahoney

ORLANDO — Performing a coronary artery bypass graft without the aortic clamp appears to minimize the risk of postoperative cerebrovascular accidents independent of the use of cardiopulmonary bypass, said Dr. Michael F. Gibson at the annual meeting of the Southern Thoracic Surgery Association.

Neurologic dysfunction is a common complication after cardiac surgery. Despite significant advances in cardiopulmonary bypass (CPB) technology, surgical techniques, and anesthesia management, central nervous system complications occur in a large number of patients undergoing surgery requiring CPB, he said.

Many comparisons between traditional arrested-heart coronary artery bypass graft (CABG) and off-pump coronary artery bypass (OPCAB) have therefore concentrated on the contribution of the cardiopulmonary bypass machine to the potential adverse outcomes, said Dr. Gibson, of the University of Oklahoma Health Sciences Center, Oklahoma City.

In contrast, in a recent investigation, Dr. Gibson and his colleagues evaluated the clinical neurologic outcomes in patients undergoing arrested-heart CABG, beating-heart cardiopulmonary bypass CABG (BHCAB), and OPCAB in whom no aortic clamp was used to restrict blood flow to the graft area.

The study included 424 patients who underwent coronary artery bypass surgery at the Health Sciences Center between July 2000 and April 2004. All the procedures were performed without the placement of an aortic clamp, and all were started as OPCAB and converted to BHCAB as required by the clinical situation, he said.

Of the 424 patients, 213 underwent CABG, 134 underwent OPCAB, and 77 underwent BHCAB. During the study period, no BHCAB or OPCAB patients were converted to CABG.

All of the patients were evaluated post operatively for clinical neurologic outcomes. Of the patients, six who underwent CABG and none who underwent BHCAB or OPCAB experienced clinically obvious cerebrovascular accidents (CVAs) in the immediate postoperative period.

“The fact that there were no immediate postoperative CVAs in the off-pump and beating-heart CPB patients implies that the application of the aortic clamp, rather than the use of cardiopulmonary bypass, is the more important culprit for such adverse outcomes in CABG surgery,” said Dr. Gibson. “Routine clampless surgery minimizes the CVA risk and may be the most important improvement that is easily obtainable with the use of off-pump and beating-heart surgery techniques.”

ORLANDO — Performing a coronary artery bypass graft without the aortic clamp appears to minimize the risk of postoperative cerebrovascular accidents independent of the use of cardiopulmonary bypass, said Dr. Michael F. Gibson at the annual meeting of the Southern Thoracic Surgery Association.

Neurologic dysfunction is a common complication after cardiac surgery. Despite significant advances in cardiopulmonary bypass (CPB) technology, surgical techniques, and anesthesia management, central nervous system complications occur in a large number of patients undergoing surgery requiring CPB, he said.

Many comparisons between traditional arrested-heart coronary artery bypass graft (CABG) and off-pump coronary artery bypass (OPCAB) have therefore concentrated on the contribution of the cardiopulmonary bypass machine to the potential adverse outcomes, said Dr. Gibson, of the University of Oklahoma Health Sciences Center, Oklahoma City.

In contrast, in a recent investigation, Dr. Gibson and his colleagues evaluated the clinical neurologic outcomes in patients undergoing arrested-heart CABG, beating-heart cardiopulmonary bypass CABG (BHCAB), and OPCAB in whom no aortic clamp was used to restrict blood flow to the graft area.

The study included 424 patients who underwent coronary artery bypass surgery at the Health Sciences Center between July 2000 and April 2004. All the procedures were performed without the placement of an aortic clamp, and all were started as OPCAB and converted to BHCAB as required by the clinical situation, he said.

Of the 424 patients, 213 underwent CABG, 134 underwent OPCAB, and 77 underwent BHCAB. During the study period, no BHCAB or OPCAB patients were converted to CABG.

All of the patients were evaluated post operatively for clinical neurologic outcomes. Of the patients, six who underwent CABG and none who underwent BHCAB or OPCAB experienced clinically obvious cerebrovascular accidents (CVAs) in the immediate postoperative period.

“The fact that there were no immediate postoperative CVAs in the off-pump and beating-heart CPB patients implies that the application of the aortic clamp, rather than the use of cardiopulmonary bypass, is the more important culprit for such adverse outcomes in CABG surgery,” said Dr. Gibson. “Routine clampless surgery minimizes the CVA risk and may be the most important improvement that is easily obtainable with the use of off-pump and beating-heart surgery techniques.”

ORLANDO — Performing a coronary artery bypass graft without the aortic clamp appears to minimize the risk of postoperative cerebrovascular accidents independent of the use of cardiopulmonary bypass, said Dr. Michael F. Gibson at the annual meeting of the Southern Thoracic Surgery Association.

Neurologic dysfunction is a common complication after cardiac surgery. Despite significant advances in cardiopulmonary bypass (CPB) technology, surgical techniques, and anesthesia management, central nervous system complications occur in a large number of patients undergoing surgery requiring CPB, he said.

Many comparisons between traditional arrested-heart coronary artery bypass graft (CABG) and off-pump coronary artery bypass (OPCAB) have therefore concentrated on the contribution of the cardiopulmonary bypass machine to the potential adverse outcomes, said Dr. Gibson, of the University of Oklahoma Health Sciences Center, Oklahoma City.

In contrast, in a recent investigation, Dr. Gibson and his colleagues evaluated the clinical neurologic outcomes in patients undergoing arrested-heart CABG, beating-heart cardiopulmonary bypass CABG (BHCAB), and OPCAB in whom no aortic clamp was used to restrict blood flow to the graft area.

The study included 424 patients who underwent coronary artery bypass surgery at the Health Sciences Center between July 2000 and April 2004. All the procedures were performed without the placement of an aortic clamp, and all were started as OPCAB and converted to BHCAB as required by the clinical situation, he said.

Of the 424 patients, 213 underwent CABG, 134 underwent OPCAB, and 77 underwent BHCAB. During the study period, no BHCAB or OPCAB patients were converted to CABG.

All of the patients were evaluated post operatively for clinical neurologic outcomes. Of the patients, six who underwent CABG and none who underwent BHCAB or OPCAB experienced clinically obvious cerebrovascular accidents (CVAs) in the immediate postoperative period.

“The fact that there were no immediate postoperative CVAs in the off-pump and beating-heart CPB patients implies that the application of the aortic clamp, rather than the use of cardiopulmonary bypass, is the more important culprit for such adverse outcomes in CABG surgery,” said Dr. Gibson. “Routine clampless surgery minimizes the CVA risk and may be the most important improvement that is easily obtainable with the use of off-pump and beating-heart surgery techniques.”

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. By comparison, in 2003, there were 1,278 reported cases of malaria in the United States—mostly acquired in Africa—resulting in seven deaths.” Although this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the signs and symptoms of the potentially fatal parasitic disease as well as the diagnostic and treatment criteria.

In terms of diagnosis, “first and foremost, malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. The signs and symptoms of the disease are often nonspecific. They can include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.” Thick smears are more sensitive but also more difficult to read. Thin smears are easier to read and are often used for diagnosing parasite species.

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said. “Delays in diagnosis and treatment can lead to life-threatening complications and worsened prognosis.”

In addition to smears, other necessary diagnostic laboratory tests include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

When malaria is diagnosed, treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

The Centers for Disease Control and Prevention says “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she reported. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum and is associated with a 15%–20% mortality rate, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy should be initiated as soon as the diagnosis is suspected.”

Besides being aware of diagnostic and treatment options, physicians should vigilantly recommend chemoprophylaxis for patients traveling to malarial areas. “The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. By comparison, in 2003, there were 1,278 reported cases of malaria in the United States—mostly acquired in Africa—resulting in seven deaths.” Although this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the signs and symptoms of the potentially fatal parasitic disease as well as the diagnostic and treatment criteria.

In terms of diagnosis, “first and foremost, malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. The signs and symptoms of the disease are often nonspecific. They can include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.” Thick smears are more sensitive but also more difficult to read. Thin smears are easier to read and are often used for diagnosing parasite species.

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said. “Delays in diagnosis and treatment can lead to life-threatening complications and worsened prognosis.”

In addition to smears, other necessary diagnostic laboratory tests include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

When malaria is diagnosed, treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

The Centers for Disease Control and Prevention says “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she reported. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum and is associated with a 15%–20% mortality rate, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy should be initiated as soon as the diagnosis is suspected.”

Besides being aware of diagnostic and treatment options, physicians should vigilantly recommend chemoprophylaxis for patients traveling to malarial areas. “The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. By comparison, in 2003, there were 1,278 reported cases of malaria in the United States—mostly acquired in Africa—resulting in seven deaths.” Although this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the signs and symptoms of the potentially fatal parasitic disease as well as the diagnostic and treatment criteria.

In terms of diagnosis, “first and foremost, malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. The signs and symptoms of the disease are often nonspecific. They can include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.” Thick smears are more sensitive but also more difficult to read. Thin smears are easier to read and are often used for diagnosing parasite species.

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said. “Delays in diagnosis and treatment can lead to life-threatening complications and worsened prognosis.”

In addition to smears, other necessary diagnostic laboratory tests include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

When malaria is diagnosed, treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

The Centers for Disease Control and Prevention says “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she reported. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum and is associated with a 15%–20% mortality rate, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy should be initiated as soon as the diagnosis is suspected.”

Besides being aware of diagnostic and treatment options, physicians should vigilantly recommend chemoprophylaxis for patients traveling to malarial areas. “The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

STOWE, VT. — Community-acquired methicillin-resistant Staphylococcus aureus infection incidence in children is increasing each year; and while sensitivities vary by region, the problem is not limited to areas of the United States previously characterized as disease “hot spots,” said Dr. Howard B. Pride at a dermatology meeting sponsored by the University of Vermont.

A review of the recent literature on this topic provides insight into these and other clinically important trends, reported Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa. For example, multiple studies have shown that MRSA is emerging in children without established risk factors for infection, and many children with MRSA are not receiving antibiotics that have been shown to be effective against the pathogen. “Surprisingly, this doesn't seem to impact recovery, as outcomes, at least initially, appear to be similar between those children who do and do not get antibiotics that offer appropriate coverage,” Dr. Pride said.

With respect to the increased incidence of community-acquired MRSA (CA-MRSA), the results of a 14-year study conducted at Driscoll Children's Hospital in Corpus Christi, Tex., demonstrated an exponential increase in community-acquired MRSA at that institution—“something that has been mirrored in many communities nationwide,” Dr. Pride said. Investigators determined that of 1,002 MRSA cases at Driscoll between 1990 and 2003, 928 (93%) were community acquired.

From 1990 through 1999, the number of CA-MRSA cases ranged from 0 to 9 per year; in 2000 there were 36 cases, and in 2003 there were 459 cases. Of particular importance, according to Dr. Pride, was the authors' observation that “categorizing children with CA-MRSA infections into those with and without risk factors is losing any clinical relevance,” because the observed antibiotic “susceptibility patterns and the spectrums of disease are becoming increasingly similar” (Arch. Pediatr. Adolesc. Med. 2005;159:980–5).

In an effort to assess the national burden and clinical effect of the increase in MRSA infections among patients without risk factors, a Centers for Disease Control and Prevention study evaluated population-based surveillance of two cities (Baltimore and Atlanta), as well as laboratory-based sentinel surveillance of 12 hospitals in Minnesota.

From the data, investigators identified 12,553 patients diagnosed with MRSA between 2001 and 2002. Of those, 1,647 infections were not associated with established risk factors and thus were classified as community-acquired MRSA disease. About 77% of these cases involved skin or soft-tissue infections, and 23% required hospitalization. The infection was fatal in one case.

The investigators found that the annual incidence of CA-MRSA varied according to site, with the most cases per 100,000 patients occurring in Atlanta. They also determined that the disease incidence was significantly higher among children younger than 2 years old and, in Atlanta, blacks were at greater risk for infection than were whites. In approximately 73% of the patients, the infecting strain of MRSA was resistant to prescribed antibiotics, yet in patients with skin or soft-tissue infections, treatment with inappropriate antimicrobials (usually β-lactam antibiotics) did not appear to correlate with differences in outcome (N. Engl. J. Med. 2005;352:1436–44).

Other studies seem to confirm the observation that CA-MRSA outcome may not be dependent on antibiotic coverage, Dr. Pride reported. Investigators from Brown University, Providence, R.I., reviewed the charts of 1,063 children with S. aureus cultures between 1997 and 2001. Of these children, 57 had confirmed MRSA infections and of those, 23 had CA-MRSA infections, predominantly in the skin and soft tissue. “Many of these children never received an antibiotic effective against MRSA, yet they still recovered,” Dr. Pride said (Pediatrics 2004;113:e347–52).

Similarly, in Dallas, among 69 children whose culture-proven CA-MRSA skin and soft-tissue abscesses were drained, there was no difference in outcome on the basis of whether they received an antibiotic (Pediatr. Infect. Dis. J. 2004;23:123–7).

Although treatment with “ineffective” antibiotics may not give a worse outcome, there are some new data that give us “an inkling that appropriate antibiotic coverage is important,” Dr. Pride said. An evaluation of a CA-MRSA outbreak in 13 high school football players on a western Pennsylvania football team showed that individuals whose initial skin infections were not treated with an antibiotic guided by bacterial sensitivities were 33 times more likely to develop a recurrent infection, compared with those who received appropriate antibiotic coverage. “Although the infections treated with only β-lactam antibiotics did not have a different outcome per se, they were at a high risk for recurrence,” Dr. Pride noted (Pediatr. Infect. Dis. J. 2005;24:841–3).

Finally, another news maker in the infectious disease realm has been the reports of increasing clindamycin resistance, Dr. Pride said. In one study comparing S. aureus cultures from pediatric patients at 57 military hospitals and clinics, clindamycin resistance increased from 0.48% from 2001 to 2002, to 4% from 2003 to 2004. While most CA-MRSA are still susceptible to clindamycin, the possibility of inducible clindamycin resistance should lead to cautious use of the agent and to the consideration of treatment alternatives, Dr. Pride concluded (Pediatr. Infect. Dis. J. 2005;24:622–6).

Dr. Pride reported no conflicts of interest with respect to the medication agents discussed in his presentation.

STOWE, VT. — Community-acquired methicillin-resistant Staphylococcus aureus infection incidence in children is increasing each year; and while sensitivities vary by region, the problem is not limited to areas of the United States previously characterized as disease “hot spots,” said Dr. Howard B. Pride at a dermatology meeting sponsored by the University of Vermont.

A review of the recent literature on this topic provides insight into these and other clinically important trends, reported Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa. For example, multiple studies have shown that MRSA is emerging in children without established risk factors for infection, and many children with MRSA are not receiving antibiotics that have been shown to be effective against the pathogen. “Surprisingly, this doesn't seem to impact recovery, as outcomes, at least initially, appear to be similar between those children who do and do not get antibiotics that offer appropriate coverage,” Dr. Pride said.

With respect to the increased incidence of community-acquired MRSA (CA-MRSA), the results of a 14-year study conducted at Driscoll Children's Hospital in Corpus Christi, Tex., demonstrated an exponential increase in community-acquired MRSA at that institution—“something that has been mirrored in many communities nationwide,” Dr. Pride said. Investigators determined that of 1,002 MRSA cases at Driscoll between 1990 and 2003, 928 (93%) were community acquired.

From 1990 through 1999, the number of CA-MRSA cases ranged from 0 to 9 per year; in 2000 there were 36 cases, and in 2003 there were 459 cases. Of particular importance, according to Dr. Pride, was the authors' observation that “categorizing children with CA-MRSA infections into those with and without risk factors is losing any clinical relevance,” because the observed antibiotic “susceptibility patterns and the spectrums of disease are becoming increasingly similar” (Arch. Pediatr. Adolesc. Med. 2005;159:980–5).

In an effort to assess the national burden and clinical effect of the increase in MRSA infections among patients without risk factors, a Centers for Disease Control and Prevention study evaluated population-based surveillance of two cities (Baltimore and Atlanta), as well as laboratory-based sentinel surveillance of 12 hospitals in Minnesota.

From the data, investigators identified 12,553 patients diagnosed with MRSA between 2001 and 2002. Of those, 1,647 infections were not associated with established risk factors and thus were classified as community-acquired MRSA disease. About 77% of these cases involved skin or soft-tissue infections, and 23% required hospitalization. The infection was fatal in one case.

The investigators found that the annual incidence of CA-MRSA varied according to site, with the most cases per 100,000 patients occurring in Atlanta. They also determined that the disease incidence was significantly higher among children younger than 2 years old and, in Atlanta, blacks were at greater risk for infection than were whites. In approximately 73% of the patients, the infecting strain of MRSA was resistant to prescribed antibiotics, yet in patients with skin or soft-tissue infections, treatment with inappropriate antimicrobials (usually β-lactam antibiotics) did not appear to correlate with differences in outcome (N. Engl. J. Med. 2005;352:1436–44).

Other studies seem to confirm the observation that CA-MRSA outcome may not be dependent on antibiotic coverage, Dr. Pride reported. Investigators from Brown University, Providence, R.I., reviewed the charts of 1,063 children with S. aureus cultures between 1997 and 2001. Of these children, 57 had confirmed MRSA infections and of those, 23 had CA-MRSA infections, predominantly in the skin and soft tissue. “Many of these children never received an antibiotic effective against MRSA, yet they still recovered,” Dr. Pride said (Pediatrics 2004;113:e347–52).

Similarly, in Dallas, among 69 children whose culture-proven CA-MRSA skin and soft-tissue abscesses were drained, there was no difference in outcome on the basis of whether they received an antibiotic (Pediatr. Infect. Dis. J. 2004;23:123–7).

Although treatment with “ineffective” antibiotics may not give a worse outcome, there are some new data that give us “an inkling that appropriate antibiotic coverage is important,” Dr. Pride said. An evaluation of a CA-MRSA outbreak in 13 high school football players on a western Pennsylvania football team showed that individuals whose initial skin infections were not treated with an antibiotic guided by bacterial sensitivities were 33 times more likely to develop a recurrent infection, compared with those who received appropriate antibiotic coverage. “Although the infections treated with only β-lactam antibiotics did not have a different outcome per se, they were at a high risk for recurrence,” Dr. Pride noted (Pediatr. Infect. Dis. J. 2005;24:841–3).

Finally, another news maker in the infectious disease realm has been the reports of increasing clindamycin resistance, Dr. Pride said. In one study comparing S. aureus cultures from pediatric patients at 57 military hospitals and clinics, clindamycin resistance increased from 0.48% from 2001 to 2002, to 4% from 2003 to 2004. While most CA-MRSA are still susceptible to clindamycin, the possibility of inducible clindamycin resistance should lead to cautious use of the agent and to the consideration of treatment alternatives, Dr. Pride concluded (Pediatr. Infect. Dis. J. 2005;24:622–6).

Dr. Pride reported no conflicts of interest with respect to the medication agents discussed in his presentation.

STOWE, VT. — Community-acquired methicillin-resistant Staphylococcus aureus infection incidence in children is increasing each year; and while sensitivities vary by region, the problem is not limited to areas of the United States previously characterized as disease “hot spots,” said Dr. Howard B. Pride at a dermatology meeting sponsored by the University of Vermont.

A review of the recent literature on this topic provides insight into these and other clinically important trends, reported Dr. Pride, a pediatric dermatologist at Geisinger Medical Center, Danville, Pa. For example, multiple studies have shown that MRSA is emerging in children without established risk factors for infection, and many children with MRSA are not receiving antibiotics that have been shown to be effective against the pathogen. “Surprisingly, this doesn't seem to impact recovery, as outcomes, at least initially, appear to be similar between those children who do and do not get antibiotics that offer appropriate coverage,” Dr. Pride said.

With respect to the increased incidence of community-acquired MRSA (CA-MRSA), the results of a 14-year study conducted at Driscoll Children's Hospital in Corpus Christi, Tex., demonstrated an exponential increase in community-acquired MRSA at that institution—“something that has been mirrored in many communities nationwide,” Dr. Pride said. Investigators determined that of 1,002 MRSA cases at Driscoll between 1990 and 2003, 928 (93%) were community acquired.

From 1990 through 1999, the number of CA-MRSA cases ranged from 0 to 9 per year; in 2000 there were 36 cases, and in 2003 there were 459 cases. Of particular importance, according to Dr. Pride, was the authors' observation that “categorizing children with CA-MRSA infections into those with and without risk factors is losing any clinical relevance,” because the observed antibiotic “susceptibility patterns and the spectrums of disease are becoming increasingly similar” (Arch. Pediatr. Adolesc. Med. 2005;159:980–5).

In an effort to assess the national burden and clinical effect of the increase in MRSA infections among patients without risk factors, a Centers for Disease Control and Prevention study evaluated population-based surveillance of two cities (Baltimore and Atlanta), as well as laboratory-based sentinel surveillance of 12 hospitals in Minnesota.

From the data, investigators identified 12,553 patients diagnosed with MRSA between 2001 and 2002. Of those, 1,647 infections were not associated with established risk factors and thus were classified as community-acquired MRSA disease. About 77% of these cases involved skin or soft-tissue infections, and 23% required hospitalization. The infection was fatal in one case.

The investigators found that the annual incidence of CA-MRSA varied according to site, with the most cases per 100,000 patients occurring in Atlanta. They also determined that the disease incidence was significantly higher among children younger than 2 years old and, in Atlanta, blacks were at greater risk for infection than were whites. In approximately 73% of the patients, the infecting strain of MRSA was resistant to prescribed antibiotics, yet in patients with skin or soft-tissue infections, treatment with inappropriate antimicrobials (usually β-lactam antibiotics) did not appear to correlate with differences in outcome (N. Engl. J. Med. 2005;352:1436–44).

Other studies seem to confirm the observation that CA-MRSA outcome may not be dependent on antibiotic coverage, Dr. Pride reported. Investigators from Brown University, Providence, R.I., reviewed the charts of 1,063 children with S. aureus cultures between 1997 and 2001. Of these children, 57 had confirmed MRSA infections and of those, 23 had CA-MRSA infections, predominantly in the skin and soft tissue. “Many of these children never received an antibiotic effective against MRSA, yet they still recovered,” Dr. Pride said (Pediatrics 2004;113:e347–52).

Similarly, in Dallas, among 69 children whose culture-proven CA-MRSA skin and soft-tissue abscesses were drained, there was no difference in outcome on the basis of whether they received an antibiotic (Pediatr. Infect. Dis. J. 2004;23:123–7).

Although treatment with “ineffective” antibiotics may not give a worse outcome, there are some new data that give us “an inkling that appropriate antibiotic coverage is important,” Dr. Pride said. An evaluation of a CA-MRSA outbreak in 13 high school football players on a western Pennsylvania football team showed that individuals whose initial skin infections were not treated with an antibiotic guided by bacterial sensitivities were 33 times more likely to develop a recurrent infection, compared with those who received appropriate antibiotic coverage. “Although the infections treated with only β-lactam antibiotics did not have a different outcome per se, they were at a high risk for recurrence,” Dr. Pride noted (Pediatr. Infect. Dis. J. 2005;24:841–3).

Finally, another news maker in the infectious disease realm has been the reports of increasing clindamycin resistance, Dr. Pride said. In one study comparing S. aureus cultures from pediatric patients at 57 military hospitals and clinics, clindamycin resistance increased from 0.48% from 2001 to 2002, to 4% from 2003 to 2004. While most CA-MRSA are still susceptible to clindamycin, the possibility of inducible clindamycin resistance should lead to cautious use of the agent and to the consideration of treatment alternatives, Dr. Pride concluded (Pediatr. Infect. Dis. J. 2005;24:622–6).

Dr. Pride reported no conflicts of interest with respect to the medication agents discussed in his presentation.

LOS ANGELES – Adjunctive therapy with lamotrigine significantly reduced the number of primary generalized tonic-clonic seizures in children and adolescents in whom such seizures are inadequately controlled with other antiepileptic drugs alone, judging from findings reported by Dr. Edwin Trevathan.

The investigators, who had funding from GlaxoSmithKline, conducted a subanalysis of a larger double-blind, placebo-controlled study that had looked at the safety and efficacy of lamotrigine (Lamictal) as an adjunctive therapy in both adults and children experiencing primary generalized tonic-clonic (PGTC) seizures, Dr. Trevathan said at the annual meeting of the Child Neurology Society.

The approved pediatric indications of lamotrigine are management of simple or complex partial seizures or Lennox-Gastaut syndrome, a devastating childhood epileptic encephalopathy. The drug is not approved for use in children under 2 years of age.

During his presentation, Dr. Trevathan said that “remarkably few randomized control trials have focused on PGTC seizures exclusively–even though it is one of the more serious forms of epilepsy–and fewer still have focused on children with these seizures,” he said.

In the larger study, 117 children, adolescents, and adults with EEG-confirmed PGTC seizures who were taking one or two concurrent antiepileptic drugs who also experienced three or more PGTC seizures during an 8-week baseline phase were randomized to adjunctive treatment with lamotrigine (58) or placebo (59).

In the majority of patients, epilepsy ideology was classified as idiopathic. Patients with evidence of partial seizures were excluded from the study, he said.

Data were collected at baseline, during the 7–12-week dose-escalation phase, and during the 12-week maintenance phase, when the dosage of the study drug and concurrent antiepileptics was held constant.

The results showed that lamotrigine reduced PGTC seizures significantly relative to baseline during both the dose-escalation and maintenance phases individually and during the entire combined treatment period, said Dr. Trevathan, director of pediatric and developmental neurology at Washington University, St. Louis.

In the post hoc subgroup analysis looking at only the results for adolescents and children–21 of whom were randomized to lamotrigine and 24 who got placebo–lamotrigine reduced the number of PGTC seizures from baseline by 77% during the entire treatment period compared with 40% for placebo. “Although the analysis was not powered to evaluate this subset of patients, the reduction is statistically significant,” Dr. Trevathan noted.

In the dose-escalation and maintenance phases, lamotrigine therapy was associated with a seizure frequency reduction from baseline in children of 72% and 83% respectively, compared with 30% and 42% in the placebo group.

There were no reports of drug-induced serious rashes–rare cases of toxic epidermal necrolysis or Stevens-Johnson syndrome have been reported with lamotrigine treatment–in either treatment group.

The most common adverse events reported during treatment were headache (10% with lamotrigine vs. 25% with placebo), nasopharyngitis (14% for lamotrigine vs. 4% for placebo), and convulsion (10% for lamotrigine vs. 13% for placebo). One patient from each treatment group dropped out of the study because of an adverse event.

“The magnitude of the effect that lamotrigine had on seizures in the subgroup analysis was approximately the same as was seen in the overall trial–basically a median percent reduction that was about twofold higher than placebo,” Dr. Trevathan said.

“Despite the fact that the subgroup analysis was underpowered because of the small sample size, it's quite clear from this data that lamotrigine appears efficacious in these patients,” he pointed out.

Because PGTC seizures are associated with a range of potentially injurious physiologic and behavioral changes before, during, and after they occur, and because they can have life-threatening complications, “effective control of these seizures is especially critical in the vulnerable child and adolescent populations,” said Dr. Trevathan. “We hope the results of this analysis will encourage more clinical trials of children and adolescents who suffer from these seizures.”

LOS ANGELES – Adjunctive therapy with lamotrigine significantly reduced the number of primary generalized tonic-clonic seizures in children and adolescents in whom such seizures are inadequately controlled with other antiepileptic drugs alone, judging from findings reported by Dr. Edwin Trevathan.

The investigators, who had funding from GlaxoSmithKline, conducted a subanalysis of a larger double-blind, placebo-controlled study that had looked at the safety and efficacy of lamotrigine (Lamictal) as an adjunctive therapy in both adults and children experiencing primary generalized tonic-clonic (PGTC) seizures, Dr. Trevathan said at the annual meeting of the Child Neurology Society.

The approved pediatric indications of lamotrigine are management of simple or complex partial seizures or Lennox-Gastaut syndrome, a devastating childhood epileptic encephalopathy. The drug is not approved for use in children under 2 years of age.

During his presentation, Dr. Trevathan said that “remarkably few randomized control trials have focused on PGTC seizures exclusively–even though it is one of the more serious forms of epilepsy–and fewer still have focused on children with these seizures,” he said.

In the larger study, 117 children, adolescents, and adults with EEG-confirmed PGTC seizures who were taking one or two concurrent antiepileptic drugs who also experienced three or more PGTC seizures during an 8-week baseline phase were randomized to adjunctive treatment with lamotrigine (58) or placebo (59).

In the majority of patients, epilepsy ideology was classified as idiopathic. Patients with evidence of partial seizures were excluded from the study, he said.

Data were collected at baseline, during the 7–12-week dose-escalation phase, and during the 12-week maintenance phase, when the dosage of the study drug and concurrent antiepileptics was held constant.

The results showed that lamotrigine reduced PGTC seizures significantly relative to baseline during both the dose-escalation and maintenance phases individually and during the entire combined treatment period, said Dr. Trevathan, director of pediatric and developmental neurology at Washington University, St. Louis.

In the post hoc subgroup analysis looking at only the results for adolescents and children–21 of whom were randomized to lamotrigine and 24 who got placebo–lamotrigine reduced the number of PGTC seizures from baseline by 77% during the entire treatment period compared with 40% for placebo. “Although the analysis was not powered to evaluate this subset of patients, the reduction is statistically significant,” Dr. Trevathan noted.

In the dose-escalation and maintenance phases, lamotrigine therapy was associated with a seizure frequency reduction from baseline in children of 72% and 83% respectively, compared with 30% and 42% in the placebo group.

There were no reports of drug-induced serious rashes–rare cases of toxic epidermal necrolysis or Stevens-Johnson syndrome have been reported with lamotrigine treatment–in either treatment group.

The most common adverse events reported during treatment were headache (10% with lamotrigine vs. 25% with placebo), nasopharyngitis (14% for lamotrigine vs. 4% for placebo), and convulsion (10% for lamotrigine vs. 13% for placebo). One patient from each treatment group dropped out of the study because of an adverse event.

“The magnitude of the effect that lamotrigine had on seizures in the subgroup analysis was approximately the same as was seen in the overall trial–basically a median percent reduction that was about twofold higher than placebo,” Dr. Trevathan said.

“Despite the fact that the subgroup analysis was underpowered because of the small sample size, it's quite clear from this data that lamotrigine appears efficacious in these patients,” he pointed out.

Because PGTC seizures are associated with a range of potentially injurious physiologic and behavioral changes before, during, and after they occur, and because they can have life-threatening complications, “effective control of these seizures is especially critical in the vulnerable child and adolescent populations,” said Dr. Trevathan. “We hope the results of this analysis will encourage more clinical trials of children and adolescents who suffer from these seizures.”

LOS ANGELES – Adjunctive therapy with lamotrigine significantly reduced the number of primary generalized tonic-clonic seizures in children and adolescents in whom such seizures are inadequately controlled with other antiepileptic drugs alone, judging from findings reported by Dr. Edwin Trevathan.

The investigators, who had funding from GlaxoSmithKline, conducted a subanalysis of a larger double-blind, placebo-controlled study that had looked at the safety and efficacy of lamotrigine (Lamictal) as an adjunctive therapy in both adults and children experiencing primary generalized tonic-clonic (PGTC) seizures, Dr. Trevathan said at the annual meeting of the Child Neurology Society.

The approved pediatric indications of lamotrigine are management of simple or complex partial seizures or Lennox-Gastaut syndrome, a devastating childhood epileptic encephalopathy. The drug is not approved for use in children under 2 years of age.

During his presentation, Dr. Trevathan said that “remarkably few randomized control trials have focused on PGTC seizures exclusively–even though it is one of the more serious forms of epilepsy–and fewer still have focused on children with these seizures,” he said.

In the larger study, 117 children, adolescents, and adults with EEG-confirmed PGTC seizures who were taking one or two concurrent antiepileptic drugs who also experienced three or more PGTC seizures during an 8-week baseline phase were randomized to adjunctive treatment with lamotrigine (58) or placebo (59).

In the majority of patients, epilepsy ideology was classified as idiopathic. Patients with evidence of partial seizures were excluded from the study, he said.

Data were collected at baseline, during the 7–12-week dose-escalation phase, and during the 12-week maintenance phase, when the dosage of the study drug and concurrent antiepileptics was held constant.

The results showed that lamotrigine reduced PGTC seizures significantly relative to baseline during both the dose-escalation and maintenance phases individually and during the entire combined treatment period, said Dr. Trevathan, director of pediatric and developmental neurology at Washington University, St. Louis.

In the post hoc subgroup analysis looking at only the results for adolescents and children–21 of whom were randomized to lamotrigine and 24 who got placebo–lamotrigine reduced the number of PGTC seizures from baseline by 77% during the entire treatment period compared with 40% for placebo. “Although the analysis was not powered to evaluate this subset of patients, the reduction is statistically significant,” Dr. Trevathan noted.

In the dose-escalation and maintenance phases, lamotrigine therapy was associated with a seizure frequency reduction from baseline in children of 72% and 83% respectively, compared with 30% and 42% in the placebo group.

There were no reports of drug-induced serious rashes–rare cases of toxic epidermal necrolysis or Stevens-Johnson syndrome have been reported with lamotrigine treatment–in either treatment group.

The most common adverse events reported during treatment were headache (10% with lamotrigine vs. 25% with placebo), nasopharyngitis (14% for lamotrigine vs. 4% for placebo), and convulsion (10% for lamotrigine vs. 13% for placebo). One patient from each treatment group dropped out of the study because of an adverse event.

“The magnitude of the effect that lamotrigine had on seizures in the subgroup analysis was approximately the same as was seen in the overall trial–basically a median percent reduction that was about twofold higher than placebo,” Dr. Trevathan said.

“Despite the fact that the subgroup analysis was underpowered because of the small sample size, it's quite clear from this data that lamotrigine appears efficacious in these patients,” he pointed out.

Because PGTC seizures are associated with a range of potentially injurious physiologic and behavioral changes before, during, and after they occur, and because they can have life-threatening complications, “effective control of these seizures is especially critical in the vulnerable child and adolescent populations,” said Dr. Trevathan. “We hope the results of this analysis will encourage more clinical trials of children and adolescents who suffer from these seizures.”

Children can be the silent victims of a parent's stroke, so stroke rehabilitation programs should be family centered to mitigate potential mental health and behavioral problems among children, said Dr. Anne Visser-Meily, of the Rehabilitation Center De Hoogstraat in Utrecht, the Netherlands, and her colleagues.

In their study, children's functioning immediately following a parental stroke was significantly predictive of their functioning at 1 year, suggesting “an enduring impact of parental stroke on a child's functioning,” the investigators said.

As such, early screening may be an important tool to identify children at risk for long-term problems. “Ensuring that these children obtain information about the consequences of stroke and its impact on the family and advice about how to deal with their feelings might support the adjustment process,” they suggested, noting that children with persistent problems may need professional help (Stroke 2005;36:2436–40).

In a cohort of stroke patients consecutively admitted to nine Dutch rehabilitation centers between April 2000 and July 2002, 55 families, including 82 children (mean age 13 years), were enrolled in the investigation to assess children's functioning immediately after and during the first year after parental stroke.

As soon as possible after the parent's stroke, spouses and children individually completed a series of questionnaires in a face-to-face interview. Information about children aged 4–7 years was collected via parent report measures. Investigators repeated the assessments 2 months and 1 year after the parental stroke.

At the first assessment, 54% of the children had at least one behavior problem or sign of depression; 21% of the children had problems that fell into the clinical range. Specifically, 30% of the children exhibited internalizing symptoms, 18% showed externalizing symptoms, and 13% had depressive symptoms. The percentage of children with these problems decreased to 23% at the 2-month assessment, with 12% in the clinical range. At the 1-year assessment, however, 29% of the children exhibited problems, with 20% meeting clinical criteria.

Although the differences between the second and third assessments were not statistically significant, “the percentage of children with subclinical or clinical scores on depression and internalizing behavior problems increased, and there was a decreasing trend in health status,” Dr. Visser-Meily and her associates said.

With respect to spousal measures, depressive symptoms decreased significantly between the first and second assessment, but not between the second and third. Perception of the quality of the marital relationship was stable between the first and second measures, but decreased significantly between the second and third.

In terms of disability, the stroke patients improved significantly between the first and third assessment, the researchers said.

Regardless of a child's functioning scores, the analysis showed that depression in the healthy parent at the time of the stroke was significantly predictive of all of the outcome scores at 1 year, said Dr. Visser-Meily and her associates.

Children can be the silent victims of a parent's stroke, so stroke rehabilitation programs should be family centered to mitigate potential mental health and behavioral problems among children, said Dr. Anne Visser-Meily, of the Rehabilitation Center De Hoogstraat in Utrecht, the Netherlands, and her colleagues.

In their study, children's functioning immediately following a parental stroke was significantly predictive of their functioning at 1 year, suggesting “an enduring impact of parental stroke on a child's functioning,” the investigators said.

As such, early screening may be an important tool to identify children at risk for long-term problems. “Ensuring that these children obtain information about the consequences of stroke and its impact on the family and advice about how to deal with their feelings might support the adjustment process,” they suggested, noting that children with persistent problems may need professional help (Stroke 2005;36:2436–40).

In a cohort of stroke patients consecutively admitted to nine Dutch rehabilitation centers between April 2000 and July 2002, 55 families, including 82 children (mean age 13 years), were enrolled in the investigation to assess children's functioning immediately after and during the first year after parental stroke.

As soon as possible after the parent's stroke, spouses and children individually completed a series of questionnaires in a face-to-face interview. Information about children aged 4–7 years was collected via parent report measures. Investigators repeated the assessments 2 months and 1 year after the parental stroke.

At the first assessment, 54% of the children had at least one behavior problem or sign of depression; 21% of the children had problems that fell into the clinical range. Specifically, 30% of the children exhibited internalizing symptoms, 18% showed externalizing symptoms, and 13% had depressive symptoms. The percentage of children with these problems decreased to 23% at the 2-month assessment, with 12% in the clinical range. At the 1-year assessment, however, 29% of the children exhibited problems, with 20% meeting clinical criteria.

Although the differences between the second and third assessments were not statistically significant, “the percentage of children with subclinical or clinical scores on depression and internalizing behavior problems increased, and there was a decreasing trend in health status,” Dr. Visser-Meily and her associates said.

With respect to spousal measures, depressive symptoms decreased significantly between the first and second assessment, but not between the second and third. Perception of the quality of the marital relationship was stable between the first and second measures, but decreased significantly between the second and third.

In terms of disability, the stroke patients improved significantly between the first and third assessment, the researchers said.

Regardless of a child's functioning scores, the analysis showed that depression in the healthy parent at the time of the stroke was significantly predictive of all of the outcome scores at 1 year, said Dr. Visser-Meily and her associates.

Children can be the silent victims of a parent's stroke, so stroke rehabilitation programs should be family centered to mitigate potential mental health and behavioral problems among children, said Dr. Anne Visser-Meily, of the Rehabilitation Center De Hoogstraat in Utrecht, the Netherlands, and her colleagues.

In their study, children's functioning immediately following a parental stroke was significantly predictive of their functioning at 1 year, suggesting “an enduring impact of parental stroke on a child's functioning,” the investigators said.

As such, early screening may be an important tool to identify children at risk for long-term problems. “Ensuring that these children obtain information about the consequences of stroke and its impact on the family and advice about how to deal with their feelings might support the adjustment process,” they suggested, noting that children with persistent problems may need professional help (Stroke 2005;36:2436–40).

In a cohort of stroke patients consecutively admitted to nine Dutch rehabilitation centers between April 2000 and July 2002, 55 families, including 82 children (mean age 13 years), were enrolled in the investigation to assess children's functioning immediately after and during the first year after parental stroke.

As soon as possible after the parent's stroke, spouses and children individually completed a series of questionnaires in a face-to-face interview. Information about children aged 4–7 years was collected via parent report measures. Investigators repeated the assessments 2 months and 1 year after the parental stroke.

At the first assessment, 54% of the children had at least one behavior problem or sign of depression; 21% of the children had problems that fell into the clinical range. Specifically, 30% of the children exhibited internalizing symptoms, 18% showed externalizing symptoms, and 13% had depressive symptoms. The percentage of children with these problems decreased to 23% at the 2-month assessment, with 12% in the clinical range. At the 1-year assessment, however, 29% of the children exhibited problems, with 20% meeting clinical criteria.

Although the differences between the second and third assessments were not statistically significant, “the percentage of children with subclinical or clinical scores on depression and internalizing behavior problems increased, and there was a decreasing trend in health status,” Dr. Visser-Meily and her associates said.

With respect to spousal measures, depressive symptoms decreased significantly between the first and second assessment, but not between the second and third. Perception of the quality of the marital relationship was stable between the first and second measures, but decreased significantly between the second and third.

In terms of disability, the stroke patients improved significantly between the first and third assessment, the researchers said.

Regardless of a child's functioning scores, the analysis showed that depression in the healthy parent at the time of the stroke was significantly predictive of all of the outcome scores at 1 year, said Dr. Visser-Meily and her associates.

BOSTON — Exercises that simulate the mechanically challenging activities of daily living lessen energy expenditures and compensations associated with knee osteoarthritis, Dr. Anthony M. Reginato said at the 10th World Congress on Osteoarthritis.

As such, functional interventions should be an important component of rehabilitation therapy, he said at the congress, which was sponsored by the Osteoarthritis Research Society International.

In a double blind, randomized trial, Dr. Reginato and his colleagues at Massachusetts General Hospital in Boston analyzed chair rise and box lifting in patients with knee osteoarthritis to determine if functional training or strengthening exercises led to improvements in mechanical energy expenditures (MEE), mechanical energy compensations (MEC), linear and angular momentum, and/or performance duration.

The study included 26 individuals, aged 43–86 years, who had Kellgren-Lawrence grade 2 or 3 knee osteoarthritis and at least two functional limitations on the SF36 physical functioning subscale. Participants were randomized to receive 8 weeks of physical therapy comprising either strength training or functional training.

“The goal of strength training is to address specific impairments, including range of motion and the ability to generate muscle force,” said Dr. Reginato.

In contrast, functional training simulates activities of daily living, such as gait, rising from a chair, and stair climbing, at different speeds and levels of difficulty, the goal of which is to improve neuromuscular control of the body, with specific focus on the individual's abilities and safety limits, he explained.

At baseline and postintervention, each participant completed a chair rise test, which required arising from a backless chair, and a box lift test, which required hoisting a plastic case holding a 5 kg metal disk onto a table.

During the tasks, ankle, knee, hip, and back MEE and MEC were calculated. Maximum whole body angular momentum, maximum whole body anterior posterior linear momentum, and maximum whole body vertical linear momentum, as well as the intervals between the start and end of each task were also assessed.

Using univariate analysis of covariance and multivariate analysis of variance to compare between-group differences in score changes relative to baseline, the investigators determined that, in the chair rise, the functional training group had significantly more improvement in energy expenditures and compensations by increasing ankle energy expenditure and decreasing back compensation, compared with the strength training group. And while there were no significant differences in chair rise interval times between the groups, the functional training group had a greater change from baseline in this measure.

In the box lift test, both groups increased their MEE in the back during the “no transfer” phase of lifting, although the strength training group had significantly higher changes in this measure, Dr. Reginato reported. In the transfer phase, the strengthening group had a significantly greater change in MEE in the back, compared with the functional group, which showed a decrease in this measure, and greater change in maximum whole body angular momentum.

The findings suggest that both functional and impairment-level interventions have important roles in the treatment of knee osteoarthritis, Dr. Reginato said.

BOSTON — Exercises that simulate the mechanically challenging activities of daily living lessen energy expenditures and compensations associated with knee osteoarthritis, Dr. Anthony M. Reginato said at the 10th World Congress on Osteoarthritis.

As such, functional interventions should be an important component of rehabilitation therapy, he said at the congress, which was sponsored by the Osteoarthritis Research Society International.

In a double blind, randomized trial, Dr. Reginato and his colleagues at Massachusetts General Hospital in Boston analyzed chair rise and box lifting in patients with knee osteoarthritis to determine if functional training or strengthening exercises led to improvements in mechanical energy expenditures (MEE), mechanical energy compensations (MEC), linear and angular momentum, and/or performance duration.

The study included 26 individuals, aged 43–86 years, who had Kellgren-Lawrence grade 2 or 3 knee osteoarthritis and at least two functional limitations on the SF36 physical functioning subscale. Participants were randomized to receive 8 weeks of physical therapy comprising either strength training or functional training.

“The goal of strength training is to address specific impairments, including range of motion and the ability to generate muscle force,” said Dr. Reginato.

In contrast, functional training simulates activities of daily living, such as gait, rising from a chair, and stair climbing, at different speeds and levels of difficulty, the goal of which is to improve neuromuscular control of the body, with specific focus on the individual's abilities and safety limits, he explained.

At baseline and postintervention, each participant completed a chair rise test, which required arising from a backless chair, and a box lift test, which required hoisting a plastic case holding a 5 kg metal disk onto a table.

During the tasks, ankle, knee, hip, and back MEE and MEC were calculated. Maximum whole body angular momentum, maximum whole body anterior posterior linear momentum, and maximum whole body vertical linear momentum, as well as the intervals between the start and end of each task were also assessed.

Using univariate analysis of covariance and multivariate analysis of variance to compare between-group differences in score changes relative to baseline, the investigators determined that, in the chair rise, the functional training group had significantly more improvement in energy expenditures and compensations by increasing ankle energy expenditure and decreasing back compensation, compared with the strength training group. And while there were no significant differences in chair rise interval times between the groups, the functional training group had a greater change from baseline in this measure.

In the box lift test, both groups increased their MEE in the back during the “no transfer” phase of lifting, although the strength training group had significantly higher changes in this measure, Dr. Reginato reported. In the transfer phase, the strengthening group had a significantly greater change in MEE in the back, compared with the functional group, which showed a decrease in this measure, and greater change in maximum whole body angular momentum.

The findings suggest that both functional and impairment-level interventions have important roles in the treatment of knee osteoarthritis, Dr. Reginato said.

BOSTON — Exercises that simulate the mechanically challenging activities of daily living lessen energy expenditures and compensations associated with knee osteoarthritis, Dr. Anthony M. Reginato said at the 10th World Congress on Osteoarthritis.

As such, functional interventions should be an important component of rehabilitation therapy, he said at the congress, which was sponsored by the Osteoarthritis Research Society International.

In a double blind, randomized trial, Dr. Reginato and his colleagues at Massachusetts General Hospital in Boston analyzed chair rise and box lifting in patients with knee osteoarthritis to determine if functional training or strengthening exercises led to improvements in mechanical energy expenditures (MEE), mechanical energy compensations (MEC), linear and angular momentum, and/or performance duration.

The study included 26 individuals, aged 43–86 years, who had Kellgren-Lawrence grade 2 or 3 knee osteoarthritis and at least two functional limitations on the SF36 physical functioning subscale. Participants were randomized to receive 8 weeks of physical therapy comprising either strength training or functional training.

“The goal of strength training is to address specific impairments, including range of motion and the ability to generate muscle force,” said Dr. Reginato.

In contrast, functional training simulates activities of daily living, such as gait, rising from a chair, and stair climbing, at different speeds and levels of difficulty, the goal of which is to improve neuromuscular control of the body, with specific focus on the individual's abilities and safety limits, he explained.

At baseline and postintervention, each participant completed a chair rise test, which required arising from a backless chair, and a box lift test, which required hoisting a plastic case holding a 5 kg metal disk onto a table.

During the tasks, ankle, knee, hip, and back MEE and MEC were calculated. Maximum whole body angular momentum, maximum whole body anterior posterior linear momentum, and maximum whole body vertical linear momentum, as well as the intervals between the start and end of each task were also assessed.

Using univariate analysis of covariance and multivariate analysis of variance to compare between-group differences in score changes relative to baseline, the investigators determined that, in the chair rise, the functional training group had significantly more improvement in energy expenditures and compensations by increasing ankle energy expenditure and decreasing back compensation, compared with the strength training group. And while there were no significant differences in chair rise interval times between the groups, the functional training group had a greater change from baseline in this measure.

In the box lift test, both groups increased their MEE in the back during the “no transfer” phase of lifting, although the strength training group had significantly higher changes in this measure, Dr. Reginato reported. In the transfer phase, the strengthening group had a significantly greater change in MEE in the back, compared with the functional group, which showed a decrease in this measure, and greater change in maximum whole body angular momentum.

The findings suggest that both functional and impairment-level interventions have important roles in the treatment of knee osteoarthritis, Dr. Reginato said.

ORLANDO, FLA. — Early clinical experience with off-pump coronary artery bypass grafting using a robotic microsurgical system suggests the procedure is a safe and effective means of myocardial revascularization, reported Dr. William F. Turner at the annual meeting of the Southern Thoracic Surgical Association.

Promising findings from an evaluation of all the patients who underwent the procedure between February 2004 and May 2005 at Trinity Mother Frances Health System in Tyler, Tex., justify the continued clinical use of the technology, said Dr. Turner of the hospital's Center of Advanced Surgery and Technology.

During the period of evaluation, surgeons used the da Vinci surgical robotic system from Intuitive Surgical (Sunnyvale, Calif.) to perform the robotic-assisted coronary artery bypass grafting (CABG) procedure in 70 patients. The system consists of a viewing and control console, and a surgical arm unit that positions and maneuvers pencil-sized surgical instruments and an endoscopic camera that are inserted through keyhole incisions between the patient's ribs.

In all of the cases, the surgeons performed the surgery through a small, muscle-sparing thoracotomy on a beating heart and without the use of cardiopulmonary bypass.

The surgical technique included endoscopic saphenous vein and radial artery harvesting, endoscopic internal mammary artery (IMA) harvesting with robot assistance, and endoscopic removal of the pericardial fat pad, localization of vessels, and determination of anatomic suitability for a minimal-access, beating-heart approach, according to Dr. Turner.

The camera ports provided endostabilizer and thoracic bulldog clamp access, and the working port was the conduit for manual, off-pump anastomoses, he said.

Patients were considered ideal candidates for the robotic procedure if they had a coronary artery diameter of approximately 1.75 mm, their left ventricular ejection fraction was greater than 30%, they were not obese, they had wide intercostal space, and they had normal pulmonary function. Contraindications included having a very large heart (cor bovinum), hemodynamic instability, decompensated heart failure, inaccessible coronary artery, and morbid obesity.

With respect to preoperative risk factors in the 70 patients, 7 had cerebrovascular disease, 9 had renal insufficiency, 18 had peripheral vascular disease, 12 were older than 75 years (the mean age was 66), 21 had chronic obstructive pulmonary disease, and 15 had diabetes.

There were no operative deaths and “very few” postoperative complications, which included bleeding in two patients that necessitated reoperation, atrial fibrillation in six patients, and chest wound infection in two patients, said Dr. Turner.

“No patient experienced neurologic complications, renal failure, or the need for more than 1 day on the ventilator,” said Dr. Turner.

The average time on the ventilator was 4 hours, and the average postoperative hospitalization was 5 days, he noted.

In addition, the average operative time per case over the entire patient series was 4 hours 43 minutes, although there was a steep, initial learning curve.

“For the first 10 cases, the average operative time per case was 6 hours 6 minutes, which decreased to 3 hours 50 minutes for the last 10 cases,” Dr. Turner commented.

The internal mammary artery was used in all but one of the patients. The mean number of grafts per patient was two.

Of the 70 patients, 3 required conversion to sternotomy. “The conversion was elective in two of the patients—one because of an intra- myocardial coronary artery and one because we were unable to harvest the IMA due to the patient's size,” said Dr. Turner.

“In the third patient, the conversion was emergent—the result of a refractory hemorrhage at the distal coronary artery. This patient was converted and underwent on-pump bypass,” he said.

To date, the postoperative survival rate remains 100%, and the cardiac event-free survival is 97%.

“Two patients were readmitted within 30 days [with graft occlusions] and required reintervention,” said Dr. Turner. One of the two patients underwent an elective repeat bypass and was discharged after 7 days; the other received medical therapy at home, he said.

Given the decreased operative time, compared with conventional CABG procedures, and the low complication rate, robotic-assisted coronary artery bypass “may pave the way to a completely endoscopic, closed chest procedure for CABG,” Dr. Turner concluded.

ORLANDO, FLA. — Early clinical experience with off-pump coronary artery bypass grafting using a robotic microsurgical system suggests the procedure is a safe and effective means of myocardial revascularization, reported Dr. William F. Turner at the annual meeting of the Southern Thoracic Surgical Association.

Promising findings from an evaluation of all the patients who underwent the procedure between February 2004 and May 2005 at Trinity Mother Frances Health System in Tyler, Tex., justify the continued clinical use of the technology, said Dr. Turner of the hospital's Center of Advanced Surgery and Technology.

During the period of evaluation, surgeons used the da Vinci surgical robotic system from Intuitive Surgical (Sunnyvale, Calif.) to perform the robotic-assisted coronary artery bypass grafting (CABG) procedure in 70 patients. The system consists of a viewing and control console, and a surgical arm unit that positions and maneuvers pencil-sized surgical instruments and an endoscopic camera that are inserted through keyhole incisions between the patient's ribs.

In all of the cases, the surgeons performed the surgery through a small, muscle-sparing thoracotomy on a beating heart and without the use of cardiopulmonary bypass.

The surgical technique included endoscopic saphenous vein and radial artery harvesting, endoscopic internal mammary artery (IMA) harvesting with robot assistance, and endoscopic removal of the pericardial fat pad, localization of vessels, and determination of anatomic suitability for a minimal-access, beating-heart approach, according to Dr. Turner.

The camera ports provided endostabilizer and thoracic bulldog clamp access, and the working port was the conduit for manual, off-pump anastomoses, he said.

Patients were considered ideal candidates for the robotic procedure if they had a coronary artery diameter of approximately 1.75 mm, their left ventricular ejection fraction was greater than 30%, they were not obese, they had wide intercostal space, and they had normal pulmonary function. Contraindications included having a very large heart (cor bovinum), hemodynamic instability, decompensated heart failure, inaccessible coronary artery, and morbid obesity.

With respect to preoperative risk factors in the 70 patients, 7 had cerebrovascular disease, 9 had renal insufficiency, 18 had peripheral vascular disease, 12 were older than 75 years (the mean age was 66), 21 had chronic obstructive pulmonary disease, and 15 had diabetes.

There were no operative deaths and “very few” postoperative complications, which included bleeding in two patients that necessitated reoperation, atrial fibrillation in six patients, and chest wound infection in two patients, said Dr. Turner.

“No patient experienced neurologic complications, renal failure, or the need for more than 1 day on the ventilator,” said Dr. Turner.

The average time on the ventilator was 4 hours, and the average postoperative hospitalization was 5 days, he noted.

In addition, the average operative time per case over the entire patient series was 4 hours 43 minutes, although there was a steep, initial learning curve.

“For the first 10 cases, the average operative time per case was 6 hours 6 minutes, which decreased to 3 hours 50 minutes for the last 10 cases,” Dr. Turner commented.

The internal mammary artery was used in all but one of the patients. The mean number of grafts per patient was two.

Of the 70 patients, 3 required conversion to sternotomy. “The conversion was elective in two of the patients—one because of an intra- myocardial coronary artery and one because we were unable to harvest the IMA due to the patient's size,” said Dr. Turner.

“In the third patient, the conversion was emergent—the result of a refractory hemorrhage at the distal coronary artery. This patient was converted and underwent on-pump bypass,” he said.

To date, the postoperative survival rate remains 100%, and the cardiac event-free survival is 97%.

“Two patients were readmitted within 30 days [with graft occlusions] and required reintervention,” said Dr. Turner. One of the two patients underwent an elective repeat bypass and was discharged after 7 days; the other received medical therapy at home, he said.

Given the decreased operative time, compared with conventional CABG procedures, and the low complication rate, robotic-assisted coronary artery bypass “may pave the way to a completely endoscopic, closed chest procedure for CABG,” Dr. Turner concluded.

ORLANDO, FLA. — Early clinical experience with off-pump coronary artery bypass grafting using a robotic microsurgical system suggests the procedure is a safe and effective means of myocardial revascularization, reported Dr. William F. Turner at the annual meeting of the Southern Thoracic Surgical Association.

Promising findings from an evaluation of all the patients who underwent the procedure between February 2004 and May 2005 at Trinity Mother Frances Health System in Tyler, Tex., justify the continued clinical use of the technology, said Dr. Turner of the hospital's Center of Advanced Surgery and Technology.

During the period of evaluation, surgeons used the da Vinci surgical robotic system from Intuitive Surgical (Sunnyvale, Calif.) to perform the robotic-assisted coronary artery bypass grafting (CABG) procedure in 70 patients. The system consists of a viewing and control console, and a surgical arm unit that positions and maneuvers pencil-sized surgical instruments and an endoscopic camera that are inserted through keyhole incisions between the patient's ribs.

In all of the cases, the surgeons performed the surgery through a small, muscle-sparing thoracotomy on a beating heart and without the use of cardiopulmonary bypass.

The surgical technique included endoscopic saphenous vein and radial artery harvesting, endoscopic internal mammary artery (IMA) harvesting with robot assistance, and endoscopic removal of the pericardial fat pad, localization of vessels, and determination of anatomic suitability for a minimal-access, beating-heart approach, according to Dr. Turner.

The camera ports provided endostabilizer and thoracic bulldog clamp access, and the working port was the conduit for manual, off-pump anastomoses, he said.

Patients were considered ideal candidates for the robotic procedure if they had a coronary artery diameter of approximately 1.75 mm, their left ventricular ejection fraction was greater than 30%, they were not obese, they had wide intercostal space, and they had normal pulmonary function. Contraindications included having a very large heart (cor bovinum), hemodynamic instability, decompensated heart failure, inaccessible coronary artery, and morbid obesity.

With respect to preoperative risk factors in the 70 patients, 7 had cerebrovascular disease, 9 had renal insufficiency, 18 had peripheral vascular disease, 12 were older than 75 years (the mean age was 66), 21 had chronic obstructive pulmonary disease, and 15 had diabetes.

There were no operative deaths and “very few” postoperative complications, which included bleeding in two patients that necessitated reoperation, atrial fibrillation in six patients, and chest wound infection in two patients, said Dr. Turner.

“No patient experienced neurologic complications, renal failure, or the need for more than 1 day on the ventilator,” said Dr. Turner.

The average time on the ventilator was 4 hours, and the average postoperative hospitalization was 5 days, he noted.

In addition, the average operative time per case over the entire patient series was 4 hours 43 minutes, although there was a steep, initial learning curve.

“For the first 10 cases, the average operative time per case was 6 hours 6 minutes, which decreased to 3 hours 50 minutes for the last 10 cases,” Dr. Turner commented.

The internal mammary artery was used in all but one of the patients. The mean number of grafts per patient was two.

Of the 70 patients, 3 required conversion to sternotomy. “The conversion was elective in two of the patients—one because of an intra- myocardial coronary artery and one because we were unable to harvest the IMA due to the patient's size,” said Dr. Turner.

“In the third patient, the conversion was emergent—the result of a refractory hemorrhage at the distal coronary artery. This patient was converted and underwent on-pump bypass,” he said.

To date, the postoperative survival rate remains 100%, and the cardiac event-free survival is 97%.

“Two patients were readmitted within 30 days [with graft occlusions] and required reintervention,” said Dr. Turner. One of the two patients underwent an elective repeat bypass and was discharged after 7 days; the other received medical therapy at home, he said.

Given the decreased operative time, compared with conventional CABG procedures, and the low complication rate, robotic-assisted coronary artery bypass “may pave the way to a completely endoscopic, closed chest procedure for CABG,” Dr. Turner concluded.

BOSTON — Lower-extremity strength training may do more to stave off the incidence and progression of knee osteoarthritis symptoms in older individuals than do conventional range-of-motion exercises, said Steven A. Mazzuca, Ph.D., at the 10th World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

Several previous studies have linked quadriceps weakness with osteoarthritis, suggesting that weak leg muscles may be a risk factor for the incidence of the condition, said Dr. Mazzuca of the division of rheumatology at Indiana University in Indianapolis. However, he noted, “research has not clearly shown whether exercises designed to improve leg strength can slow the progression of ostearthritis.”

Dr. Mazzuca and colleagues randomized a population-based sample of 221 subjects (mean age 69 years) into either a resistance-based strength-training intervention or a range-of-motion intervention. In both groups, subjects exercised three times per week for 12 weeks at a fitness facility, then transitioned to home-based exercise by month 12 and twice-yearly “booster” sessions until month 30. Attendance at scheduled exercise sessions was similar between both groups. Of the original 221 subjects, 154 completed the study, including 72 from the strength-training group and 82 from the range-of-motion group, Dr. Mazzuca noted.

At 30 months, those individuals randomized to quadriceps strength training retained more strength than did those in the range-of-motion group, and exhibited marginally less frequent progressive joint-space narrowing, said Dr. Mazzuca.

“Strength training decreased the rate of joint-space narrowing by 26%” compared with range-of-motion subjects, he said.

In addition, the percentage of osteoarthritic knees exhibiting more than 0.50-mm joint-space narrowing was marginally smaller in the strength-training group than it was in the range-of-motion group.

However, among knees that were normal at baseline in the strength-training group, the investigators observed an increase in incident joint-space narrowing greater than 0.50 mm, compared with the range-of-motion group. This was a finding that could not be explained, said Dr. Mazzuca.

BOSTON — Lower-extremity strength training may do more to stave off the incidence and progression of knee osteoarthritis symptoms in older individuals than do conventional range-of-motion exercises, said Steven A. Mazzuca, Ph.D., at the 10th World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

Several previous studies have linked quadriceps weakness with osteoarthritis, suggesting that weak leg muscles may be a risk factor for the incidence of the condition, said Dr. Mazzuca of the division of rheumatology at Indiana University in Indianapolis. However, he noted, “research has not clearly shown whether exercises designed to improve leg strength can slow the progression of ostearthritis.”

Dr. Mazzuca and colleagues randomized a population-based sample of 221 subjects (mean age 69 years) into either a resistance-based strength-training intervention or a range-of-motion intervention. In both groups, subjects exercised three times per week for 12 weeks at a fitness facility, then transitioned to home-based exercise by month 12 and twice-yearly “booster” sessions until month 30. Attendance at scheduled exercise sessions was similar between both groups. Of the original 221 subjects, 154 completed the study, including 72 from the strength-training group and 82 from the range-of-motion group, Dr. Mazzuca noted.

At 30 months, those individuals randomized to quadriceps strength training retained more strength than did those in the range-of-motion group, and exhibited marginally less frequent progressive joint-space narrowing, said Dr. Mazzuca.

“Strength training decreased the rate of joint-space narrowing by 26%” compared with range-of-motion subjects, he said.

In addition, the percentage of osteoarthritic knees exhibiting more than 0.50-mm joint-space narrowing was marginally smaller in the strength-training group than it was in the range-of-motion group.

However, among knees that were normal at baseline in the strength-training group, the investigators observed an increase in incident joint-space narrowing greater than 0.50 mm, compared with the range-of-motion group. This was a finding that could not be explained, said Dr. Mazzuca.

BOSTON — Lower-extremity strength training may do more to stave off the incidence and progression of knee osteoarthritis symptoms in older individuals than do conventional range-of-motion exercises, said Steven A. Mazzuca, Ph.D., at the 10th World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

Several previous studies have linked quadriceps weakness with osteoarthritis, suggesting that weak leg muscles may be a risk factor for the incidence of the condition, said Dr. Mazzuca of the division of rheumatology at Indiana University in Indianapolis. However, he noted, “research has not clearly shown whether exercises designed to improve leg strength can slow the progression of ostearthritis.”

Dr. Mazzuca and colleagues randomized a population-based sample of 221 subjects (mean age 69 years) into either a resistance-based strength-training intervention or a range-of-motion intervention. In both groups, subjects exercised three times per week for 12 weeks at a fitness facility, then transitioned to home-based exercise by month 12 and twice-yearly “booster” sessions until month 30. Attendance at scheduled exercise sessions was similar between both groups. Of the original 221 subjects, 154 completed the study, including 72 from the strength-training group and 82 from the range-of-motion group, Dr. Mazzuca noted.

At 30 months, those individuals randomized to quadriceps strength training retained more strength than did those in the range-of-motion group, and exhibited marginally less frequent progressive joint-space narrowing, said Dr. Mazzuca.

“Strength training decreased the rate of joint-space narrowing by 26%” compared with range-of-motion subjects, he said.

In addition, the percentage of osteoarthritic knees exhibiting more than 0.50-mm joint-space narrowing was marginally smaller in the strength-training group than it was in the range-of-motion group.

However, among knees that were normal at baseline in the strength-training group, the investigators observed an increase in incident joint-space narrowing greater than 0.50 mm, compared with the range-of-motion group. This was a finding that could not be explained, said Dr. Mazzuca.

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. “In 2003, there were 1,278 reported cases in the United States—mostly acquired in Africa—resulting in seven deaths.” While this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the diagnostic and treatment criteria of the potentially fatal disease.

In terms of diagnosis, “malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. Signs and symptoms are often nonspecific and include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.”

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said.

In addition to smears, lab tests should include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

Treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

According to the Centers for Disease Control and Prevention, “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she said. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy initiated as soon as the diagnosis is suspected.”

Some of the common features of fatal malaria in this country include lack of adequate or any chemoprophylaxis; failure to associate symptoms with potential for malaria and seek medical care; failure of health care provider to consider a malaria diagnosis, to initiate prompt treatment, or to address potential for complications; and the assumption that severe malaria cannot occur in an immune host, said Dr. Barnett.

Physicians should be vigilant in recommending chemoprophylaxis for patients who will be traveling to malarial areas.

“The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

'Malaria should always be in the differential of a febrile patient who has visited a malarial area.' DR. BARNETT

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. “In 2003, there were 1,278 reported cases in the United States—mostly acquired in Africa—resulting in seven deaths.” While this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the diagnostic and treatment criteria of the potentially fatal disease.

In terms of diagnosis, “malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. Signs and symptoms are often nonspecific and include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.”

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said.

In addition to smears, lab tests should include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

Treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

According to the Centers for Disease Control and Prevention, “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she said. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy initiated as soon as the diagnosis is suspected.”

Some of the common features of fatal malaria in this country include lack of adequate or any chemoprophylaxis; failure to associate symptoms with potential for malaria and seek medical care; failure of health care provider to consider a malaria diagnosis, to initiate prompt treatment, or to address potential for complications; and the assumption that severe malaria cannot occur in an immune host, said Dr. Barnett.

Physicians should be vigilant in recommending chemoprophylaxis for patients who will be traveling to malarial areas.

“The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

'Malaria should always be in the differential of a febrile patient who has visited a malarial area.' DR. BARNETT

CAMBRIDGE, MASS. — Increases in travel between the United States and developing countries, as well as immigration from developing countries to the United States, raises the potential for transmission of malaria within the United States, Dr. Elizabeth D. Barnett said at a conference on pediatric infectious diseases.

“In 1973, there were 22 reported cases of malaria in the United States,” reported Dr. Barnett, director of the International Clinic at Boston Medical Center. “In 2003, there were 1,278 reported cases in the United States—mostly acquired in Africa—resulting in seven deaths.” While this number is down from the 1980 high of 1,864 reported cases, U.S. physicians must be aware of the diagnostic and treatment criteria of the potentially fatal disease.

In terms of diagnosis, “malaria should always be in the differential of a febrile patient who has visited a malarial area,” said Dr. Barnett at the meeting, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS. Signs and symptoms are often nonspecific and include fever—which is almost always present but may be periodic—headache, chills, sweating, back pain, myalgias, diarrhea, nausea, vomiting, and cough.

“A malaria diagnosis requires an examination of blood smears. Typically multiple smears are needed because the level of parasitemia can vary,” she said. “If malaria is suspected [but not supported by initial smears], multiple smears over multiple days may be needed.”

Because of the nonspecificity of symptoms, “it's important to maintain a high index of suspicion for malaria,” Dr. Barnett said.

In addition to smears, lab tests should include complete blood count to identify anemia and/or thrombocytopenia, liver function tests to assess the degree of hemolysis and liver function impairment, glucose, blood urea nitrogen and creatinine, and urinalysis.

Treatment should be based on the severity of the condition and local drug resistance patterns. For uncomplicated malaria, “assume Plasmodium falciparum is the species until this can be confirmed, and choose [an oral] drug regimen based on regional resistance patterns,” said Dr. Barnett.

According to the Centers for Disease Control and Prevention, “chloroquine [Aralen] is the treatment of choice in regions where there is no chloroquine resistance,” she said. In regions with chloroquine-resistant plasmodia, treatment options include quinine in combination with doxycycline, tetracycline, or clindamycin; atovaquone in combination with proguanil (Malarone); or mefloquine (Lariam), but only if it is not being used prophylactically.

More aggressive treatment is required for complicated malaria (coma, renal failure), which is almost always caused by P. falciparum, said Dr. Barnett. “These patients should be hospitalized and parenteral therapy initiated as soon as the diagnosis is suspected.”

Some of the common features of fatal malaria in this country include lack of adequate or any chemoprophylaxis; failure to associate symptoms with potential for malaria and seek medical care; failure of health care provider to consider a malaria diagnosis, to initiate prompt treatment, or to address potential for complications; and the assumption that severe malaria cannot occur in an immune host, said Dr. Barnett.

Physicians should be vigilant in recommending chemoprophylaxis for patients who will be traveling to malarial areas.

“The prophylactic drug of choice is chloroquine if travel will be to areas with no reported chloroquine resistance,” said Dr. Barnett. “If travel will be to areas with chloroquine resistance, prophylactic options include mefloquine or atovaquone-proguanil. Doxycycline can be considered for children who are at least 8 years of age, and primaquine can be used in rare situations, such as when there are contraindications to all of the other alternatives. G6PD [glucose-6-phosphate dehydrogenase] deficiency must be ruled out before prescribing.”

Ideally, malaria prophylaxis should begin 1–2 weeks prior to travel (2–3 days for Malarone) and should continue weekly during the trip and for 4 weeks (7 days for Malarone) after leaving the area.

'Malaria should always be in the differential of a febrile patient who has visited a malarial area.' DR. BARNETT

LOS ANGELES — Magnetic resonance imaging is useful for identifying the etiology of new-onset afebrile seizures in infancy and, when available, should be included as a part of the standard diagnostic evaluation in this population, according to Dr. William S. Benko.

Of 103 MRIs performed in 144 infants presenting to the emergency department of Children's National Medical Center in Washington between January 2001 and January 2005 with new-onset afebrile seizures (NOAS), 40% detected diagnostic abnormalities related to the seizures, Dr. Benko said in a presentation at the annual meeting of the Child Neurology Society.

By comparison, in 136 of the 144 infants who underwent CT, abnormalities were detected in 42% of the scans; however, 15% of these were deemed incidental findings.

Fifteen of the infants with normal CT scans had abnormal MRIs. “In the majority of these CT-negative, MRI-positive patients, the CT scans did not identify focal abnormalities,” said Dr. Benko of the National Institute of Neurological Disorders and Stroke in Bethesda, Md.

According to practice parameters published in 2000 by the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society, the evaluation of a first nonfebrile seizure in a child should include EEG as a routine part of the diagnostic evaluation to predict the risk of recurrence and to classify the seizure type and epilepsy syndrome (Neurology 2000;55:616–23).

There was insufficient evidence for the routine use of other studies, such as lumbar puncture and neuroimaging, so these were deemed warranted only under specific circumstances and at a neurologist's discretion, according to the parameters.

More studies with large, well characterized samples were needed, according to the parameter, before neuroimaging could be considered for routine evaluation of NOAS.

Toward that end, Dr. Benko and colleagues investigated a prospective cohort of 1,189 patients presenting to the hospital's emergency department identified with possible NOAS.

Out of the entire cohort, 144 patients were infants. By the time of presentation to the emergency department, 82% of the infants had experienced two or more seizures. All of the patients were evaluated by a child neurologist on the basis of the patient history: laboratory values, including complete blood count, electrolytes, urinalysis, and toxicology screen; 24-hour observation; electroencephalography; and CT, MRI, and/or lumbar puncture at the clinician's discretion.

“In this afebrile population, we found that CBC, urinalysis, and toxicology screens were not at all useful or contributory,” Dr. Benko said. Of 59 infants who were given lumbar punctures, 90% had normal results and 5 had evidence of pleocytosis.

Treatable electrolyte abnormalities, including hypocalcemia, hyponatremia, and hypoglycemia were detected in five of the children. Electroencephalography showed abnormal results in 62% of patients, including focal abnormalities, hypsarrhythmia, and generalized spikes.

By comparison, neuroimaging results were particularly revealing, Dr. Benko said. With CT, congenital malformations were identified in 12% of the patients imaged, evidence of trauma was seen in 5%, and atrophy was evident in 3%.

Among the patients scanned by MRI, dysplasia was seen in 14%. These abnormalities included focal diffuse involvement, dysgenesis, heterotopias, Aicardi syndrome, and Dandy Walker malformation.

MRI also detected vascular events in 8% of patients. These included new and old cerebrovascular accidents, hemorrhage, subdural hematoma, and Sturge-Weber syndrome.

The abnormalities noted on MRI but missed on CT included dysplasia, mesial temporal sclerosis, cerebrovascular accidents, and tuberous sclerosis, he said. “The yield of CT-negative, MRI-positive findings was highest in patients with focal neurologic exam, neurodevelopmental delay, focal EEG, focal seizure, [and MRI evidence of right mesial temporal sclerosis].”

The decision to perform MRI was made by the treating neurologist, raising the possibility of a selection bias, Dr. Benko said.

In addition, the findings are limited by the fact that not all the patients who underwent CT scans also underwent MRIs, concluded Dr. Benko, who conducted the investigation during his pediatric neurology fellowship at Children's National Medical Center.

This MRI sagittal image shows a single subependymal lesion not seen on CT.

A proton density axial image shows tubers of tuberous sclerosis complex. Photos courtesy Dr. William S. Benko

LOS ANGELES — Magnetic resonance imaging is useful for identifying the etiology of new-onset afebrile seizures in infancy and, when available, should be included as a part of the standard diagnostic evaluation in this population, according to Dr. William S. Benko.

Of 103 MRIs performed in 144 infants presenting to the emergency department of Children's National Medical Center in Washington between January 2001 and January 2005 with new-onset afebrile seizures (NOAS), 40% detected diagnostic abnormalities related to the seizures, Dr. Benko said in a presentation at the annual meeting of the Child Neurology Society.

By comparison, in 136 of the 144 infants who underwent CT, abnormalities were detected in 42% of the scans; however, 15% of these were deemed incidental findings.

Fifteen of the infants with normal CT scans had abnormal MRIs. “In the majority of these CT-negative, MRI-positive patients, the CT scans did not identify focal abnormalities,” said Dr. Benko of the National Institute of Neurological Disorders and Stroke in Bethesda, Md.

According to practice parameters published in 2000 by the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society, the evaluation of a first nonfebrile seizure in a child should include EEG as a routine part of the diagnostic evaluation to predict the risk of recurrence and to classify the seizure type and epilepsy syndrome (Neurology 2000;55:616–23).

There was insufficient evidence for the routine use of other studies, such as lumbar puncture and neuroimaging, so these were deemed warranted only under specific circumstances and at a neurologist's discretion, according to the parameters.

More studies with large, well characterized samples were needed, according to the parameter, before neuroimaging could be considered for routine evaluation of NOAS.

Toward that end, Dr. Benko and colleagues investigated a prospective cohort of 1,189 patients presenting to the hospital's emergency department identified with possible NOAS.

Out of the entire cohort, 144 patients were infants. By the time of presentation to the emergency department, 82% of the infants had experienced two or more seizures. All of the patients were evaluated by a child neurologist on the basis of the patient history: laboratory values, including complete blood count, electrolytes, urinalysis, and toxicology screen; 24-hour observation; electroencephalography; and CT, MRI, and/or lumbar puncture at the clinician's discretion.

“In this afebrile population, we found that CBC, urinalysis, and toxicology screens were not at all useful or contributory,” Dr. Benko said. Of 59 infants who were given lumbar punctures, 90% had normal results and 5 had evidence of pleocytosis.

Treatable electrolyte abnormalities, including hypocalcemia, hyponatremia, and hypoglycemia were detected in five of the children. Electroencephalography showed abnormal results in 62% of patients, including focal abnormalities, hypsarrhythmia, and generalized spikes.

By comparison, neuroimaging results were particularly revealing, Dr. Benko said. With CT, congenital malformations were identified in 12% of the patients imaged, evidence of trauma was seen in 5%, and atrophy was evident in 3%.

Among the patients scanned by MRI, dysplasia was seen in 14%. These abnormalities included focal diffuse involvement, dysgenesis, heterotopias, Aicardi syndrome, and Dandy Walker malformation.

MRI also detected vascular events in 8% of patients. These included new and old cerebrovascular accidents, hemorrhage, subdural hematoma, and Sturge-Weber syndrome.

The abnormalities noted on MRI but missed on CT included dysplasia, mesial temporal sclerosis, cerebrovascular accidents, and tuberous sclerosis, he said. “The yield of CT-negative, MRI-positive findings was highest in patients with focal neurologic exam, neurodevelopmental delay, focal EEG, focal seizure, [and MRI evidence of right mesial temporal sclerosis].”

The decision to perform MRI was made by the treating neurologist, raising the possibility of a selection bias, Dr. Benko said.

In addition, the findings are limited by the fact that not all the patients who underwent CT scans also underwent MRIs, concluded Dr. Benko, who conducted the investigation during his pediatric neurology fellowship at Children's National Medical Center.

This MRI sagittal image shows a single subependymal lesion not seen on CT.

A proton density axial image shows tubers of tuberous sclerosis complex. Photos courtesy Dr. William S. Benko

LOS ANGELES — Magnetic resonance imaging is useful for identifying the etiology of new-onset afebrile seizures in infancy and, when available, should be included as a part of the standard diagnostic evaluation in this population, according to Dr. William S. Benko.

Of 103 MRIs performed in 144 infants presenting to the emergency department of Children's National Medical Center in Washington between January 2001 and January 2005 with new-onset afebrile seizures (NOAS), 40% detected diagnostic abnormalities related to the seizures, Dr. Benko said in a presentation at the annual meeting of the Child Neurology Society.

By comparison, in 136 of the 144 infants who underwent CT, abnormalities were detected in 42% of the scans; however, 15% of these were deemed incidental findings.

Fifteen of the infants with normal CT scans had abnormal MRIs. “In the majority of these CT-negative, MRI-positive patients, the CT scans did not identify focal abnormalities,” said Dr. Benko of the National Institute of Neurological Disorders and Stroke in Bethesda, Md.

According to practice parameters published in 2000 by the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society, the evaluation of a first nonfebrile seizure in a child should include EEG as a routine part of the diagnostic evaluation to predict the risk of recurrence and to classify the seizure type and epilepsy syndrome (Neurology 2000;55:616–23).

There was insufficient evidence for the routine use of other studies, such as lumbar puncture and neuroimaging, so these were deemed warranted only under specific circumstances and at a neurologist's discretion, according to the parameters.

More studies with large, well characterized samples were needed, according to the parameter, before neuroimaging could be considered for routine evaluation of NOAS.

Toward that end, Dr. Benko and colleagues investigated a prospective cohort of 1,189 patients presenting to the hospital's emergency department identified with possible NOAS.

Out of the entire cohort, 144 patients were infants. By the time of presentation to the emergency department, 82% of the infants had experienced two or more seizures. All of the patients were evaluated by a child neurologist on the basis of the patient history: laboratory values, including complete blood count, electrolytes, urinalysis, and toxicology screen; 24-hour observation; electroencephalography; and CT, MRI, and/or lumbar puncture at the clinician's discretion.

“In this afebrile population, we found that CBC, urinalysis, and toxicology screens were not at all useful or contributory,” Dr. Benko said. Of 59 infants who were given lumbar punctures, 90% had normal results and 5 had evidence of pleocytosis.

Treatable electrolyte abnormalities, including hypocalcemia, hyponatremia, and hypoglycemia were detected in five of the children. Electroencephalography showed abnormal results in 62% of patients, including focal abnormalities, hypsarrhythmia, and generalized spikes.

By comparison, neuroimaging results were particularly revealing, Dr. Benko said. With CT, congenital malformations were identified in 12% of the patients imaged, evidence of trauma was seen in 5%, and atrophy was evident in 3%.

Among the patients scanned by MRI, dysplasia was seen in 14%. These abnormalities included focal diffuse involvement, dysgenesis, heterotopias, Aicardi syndrome, and Dandy Walker malformation.

MRI also detected vascular events in 8% of patients. These included new and old cerebrovascular accidents, hemorrhage, subdural hematoma, and Sturge-Weber syndrome.

The abnormalities noted on MRI but missed on CT included dysplasia, mesial temporal sclerosis, cerebrovascular accidents, and tuberous sclerosis, he said. “The yield of CT-negative, MRI-positive findings was highest in patients with focal neurologic exam, neurodevelopmental delay, focal EEG, focal seizure, [and MRI evidence of right mesial temporal sclerosis].”

The decision to perform MRI was made by the treating neurologist, raising the possibility of a selection bias, Dr. Benko said.

In addition, the findings are limited by the fact that not all the patients who underwent CT scans also underwent MRIs, concluded Dr. Benko, who conducted the investigation during his pediatric neurology fellowship at Children's National Medical Center.

This MRI sagittal image shows a single subependymal lesion not seen on CT.

A proton density axial image shows tubers of tuberous sclerosis complex. Photos courtesy Dr. William S. Benko