Diana Mahoney

BOSTON — A strong and statistically significant correlation between systemic C-reactive protein levels and inflammatory infiltrates in the joints of individuals with osteoarthritis in a recent study offers clues into the mechanistic link between the systemic inflammatory marker and disease activity, Dr. Carla R. Scanzello said at the 10th World Congress on Osteoarthritis sponsored by the Osteoarthritis Research Society International.

Previous studies have demonstrated an association between systemic C-reactive protein (CRP) levels and disease progression, clinical severity, and pain in osteoarthritis.

But these findings are the first to link CRP levels to local inflammatory findings, Dr. Scanzello reported in a poster presentation.

To investigate the relationship between systemic CRP levels and local joint inflammation, Dr. Scanzello, with lead investigator Dr. Andrew Pearle and colleagues at the Hospital for Special Surgery in New York, evaluated the appearance, histology, and interleukin-6 (IL-6) levels in synovial fluid from 52 patients with ideopathic arthritis.

The investigators collected plasma and synovial membrane specimens from these patients, all of whom were scheduled to undergo total knee or hip arthroplasty or knee arthroscopy for osteoarthritis.

The researchers also collected joint fluid samples from a subgroup of 26 of these patients prior to surgery.

Synovial membrane inflammation was graded intraoperatively and by subsequent histologic examination, and synovial fluid IL-6 levels and plasma CRP levels were measured using a high-sensitivity enzyme-linked immunosorbent assay.

Of the full cohort, 26 patients had low-grade inflammatory infiltrates on histologic analysis and 4 patients had high-grade infiltrates.

The mean CRP level in the patients with inflammatory infiltrates was 4.7 μg/mL, which was significantly higher than the mean of 1.7 μg/mL in patients without inflammation. In addition, the degree of inflammation had a statistically significant correlation with systemic CRP levels (r = 0.42), Dr. Scanzello commented.

While there was no significant difference between patients with and without synovial infiltrates in mean age, body mass index, or gender, “there was a trend toward slightly higher BMI in the group with histologic infiltrates,” Dr. Scanzello said.

With respect to measures of IL-6, a known regulator of the acute phase response, “the plasma IL-6 levels were difficult to detect in most of the osteoarthritis patients.”

However, the average synovial fluid IL-6 level in the patients from whom synovial fluid samples were collected was 88.02 pg/mL, according to Dr. Scanzello.

There was a significant correlation between those levels and systemic CRP levels (r = 0.63), she said.

The investigators observed modest but statistically significant correlations between CRP levels and BMI, and multiple linear regression analysis revealed that both BMI and degree of inflammation were significantly associated with CRP levels.

While the significance of the BMI connection is unclear, “it's possible that patients with elevated BMI are more likely to develop inflammation within the joint,” said Dr. Scanzello.

The correlation between CRP and inflammatory infiltrates found in this investigation, taken together with results from earlier studies linking high CRP levels with more rapid disease progression and more severe pain, suggests that “osteoarthritis patients with elevated high-sensitivity CRP may make up a subgroup of patients with synovial inflammation and with a more aggressive form of disease,” Dr. Scanzello concluded.

BOSTON — A strong and statistically significant correlation between systemic C-reactive protein levels and inflammatory infiltrates in the joints of individuals with osteoarthritis in a recent study offers clues into the mechanistic link between the systemic inflammatory marker and disease activity, Dr. Carla R. Scanzello said at the 10th World Congress on Osteoarthritis sponsored by the Osteoarthritis Research Society International.

Previous studies have demonstrated an association between systemic C-reactive protein (CRP) levels and disease progression, clinical severity, and pain in osteoarthritis.

But these findings are the first to link CRP levels to local inflammatory findings, Dr. Scanzello reported in a poster presentation.

To investigate the relationship between systemic CRP levels and local joint inflammation, Dr. Scanzello, with lead investigator Dr. Andrew Pearle and colleagues at the Hospital for Special Surgery in New York, evaluated the appearance, histology, and interleukin-6 (IL-6) levels in synovial fluid from 52 patients with ideopathic arthritis.

The investigators collected plasma and synovial membrane specimens from these patients, all of whom were scheduled to undergo total knee or hip arthroplasty or knee arthroscopy for osteoarthritis.

The researchers also collected joint fluid samples from a subgroup of 26 of these patients prior to surgery.

Synovial membrane inflammation was graded intraoperatively and by subsequent histologic examination, and synovial fluid IL-6 levels and plasma CRP levels were measured using a high-sensitivity enzyme-linked immunosorbent assay.

Of the full cohort, 26 patients had low-grade inflammatory infiltrates on histologic analysis and 4 patients had high-grade infiltrates.

The mean CRP level in the patients with inflammatory infiltrates was 4.7 μg/mL, which was significantly higher than the mean of 1.7 μg/mL in patients without inflammation. In addition, the degree of inflammation had a statistically significant correlation with systemic CRP levels (r = 0.42), Dr. Scanzello commented.

While there was no significant difference between patients with and without synovial infiltrates in mean age, body mass index, or gender, “there was a trend toward slightly higher BMI in the group with histologic infiltrates,” Dr. Scanzello said.

With respect to measures of IL-6, a known regulator of the acute phase response, “the plasma IL-6 levels were difficult to detect in most of the osteoarthritis patients.”

However, the average synovial fluid IL-6 level in the patients from whom synovial fluid samples were collected was 88.02 pg/mL, according to Dr. Scanzello.

There was a significant correlation between those levels and systemic CRP levels (r = 0.63), she said.

The investigators observed modest but statistically significant correlations between CRP levels and BMI, and multiple linear regression analysis revealed that both BMI and degree of inflammation were significantly associated with CRP levels.

While the significance of the BMI connection is unclear, “it's possible that patients with elevated BMI are more likely to develop inflammation within the joint,” said Dr. Scanzello.

The correlation between CRP and inflammatory infiltrates found in this investigation, taken together with results from earlier studies linking high CRP levels with more rapid disease progression and more severe pain, suggests that “osteoarthritis patients with elevated high-sensitivity CRP may make up a subgroup of patients with synovial inflammation and with a more aggressive form of disease,” Dr. Scanzello concluded.

BOSTON — A strong and statistically significant correlation between systemic C-reactive protein levels and inflammatory infiltrates in the joints of individuals with osteoarthritis in a recent study offers clues into the mechanistic link between the systemic inflammatory marker and disease activity, Dr. Carla R. Scanzello said at the 10th World Congress on Osteoarthritis sponsored by the Osteoarthritis Research Society International.

Previous studies have demonstrated an association between systemic C-reactive protein (CRP) levels and disease progression, clinical severity, and pain in osteoarthritis.

But these findings are the first to link CRP levels to local inflammatory findings, Dr. Scanzello reported in a poster presentation.

To investigate the relationship between systemic CRP levels and local joint inflammation, Dr. Scanzello, with lead investigator Dr. Andrew Pearle and colleagues at the Hospital for Special Surgery in New York, evaluated the appearance, histology, and interleukin-6 (IL-6) levels in synovial fluid from 52 patients with ideopathic arthritis.

The investigators collected plasma and synovial membrane specimens from these patients, all of whom were scheduled to undergo total knee or hip arthroplasty or knee arthroscopy for osteoarthritis.

The researchers also collected joint fluid samples from a subgroup of 26 of these patients prior to surgery.

Synovial membrane inflammation was graded intraoperatively and by subsequent histologic examination, and synovial fluid IL-6 levels and plasma CRP levels were measured using a high-sensitivity enzyme-linked immunosorbent assay.

Of the full cohort, 26 patients had low-grade inflammatory infiltrates on histologic analysis and 4 patients had high-grade infiltrates.

The mean CRP level in the patients with inflammatory infiltrates was 4.7 μg/mL, which was significantly higher than the mean of 1.7 μg/mL in patients without inflammation. In addition, the degree of inflammation had a statistically significant correlation with systemic CRP levels (r = 0.42), Dr. Scanzello commented.

While there was no significant difference between patients with and without synovial infiltrates in mean age, body mass index, or gender, “there was a trend toward slightly higher BMI in the group with histologic infiltrates,” Dr. Scanzello said.

With respect to measures of IL-6, a known regulator of the acute phase response, “the plasma IL-6 levels were difficult to detect in most of the osteoarthritis patients.”

However, the average synovial fluid IL-6 level in the patients from whom synovial fluid samples were collected was 88.02 pg/mL, according to Dr. Scanzello.

There was a significant correlation between those levels and systemic CRP levels (r = 0.63), she said.

The investigators observed modest but statistically significant correlations between CRP levels and BMI, and multiple linear regression analysis revealed that both BMI and degree of inflammation were significantly associated with CRP levels.

While the significance of the BMI connection is unclear, “it's possible that patients with elevated BMI are more likely to develop inflammation within the joint,” said Dr. Scanzello.

The correlation between CRP and inflammatory infiltrates found in this investigation, taken together with results from earlier studies linking high CRP levels with more rapid disease progression and more severe pain, suggests that “osteoarthritis patients with elevated high-sensitivity CRP may make up a subgroup of patients with synovial inflammation and with a more aggressive form of disease,” Dr. Scanzello concluded.

ORLANDO — Infants younger than 3 months who undergo repair of complete atrioventricular canal fare as well as older infants following the procedure, said Dr. R. Ramesh Singh at the annual meeting of the Southern Thoracic Surgical Association.

Numerous studies have shown that better outcomes are achieved when complete atrioventricular canal (CAVC) repair takes place within the first 6 months of life to prevent the development of heart failure and long-term pulmonary vascular changes resulting from a substantial increase in blood flow and pressure in the lung circulation. The demonstrated efficacy of CAVC surgical repair over the last 20 years—most notably a drop in mortality from about 25% to 3%—has led some surgical centers to adopt a more aggressive repair approach by operating on infants within the first 3 months of life, particularly in children with Down syndrome, who are more vulnerable to early pulmonary vascular changes than children without the condition, Dr. Singh said.

To determine whether the more aggressive approach is associated with increased morbidity or mortality, Dr. Singh and colleagues at the University of Virginia Health System, Charlottesville, reviewed the outcomes of 65 infants who underwent CAVC repair at their institution between 1990 and 2004. “The study was prompted in part by the difficulty thoracic surgery board examinees have had in dealing with this clinical scenario, simply because there is no consensus on the best timing of surgery,” said Dr. Singh.

Of the 65 infants, 26 underwent CAVC repair surgery on or before 3 months of age, and 39 had the procedure done after 3 months (mean age between 5 and 6 months). Other than age, characteristics of infants in both groups were similar, “although there was a significantly higher preponderance of patients with Down syndrome in the older group,” said Dr. Singh. “Down syndrome in itself is not an independent risk factor of [postsurgical] morbidity or mortality in this patient population,” he said.

All infants underwent preoperative echocardiography, and 13 of them—6 in the younger group, 7 in the older—also had cardiac catheterization evaluations. None of the patients had undergone previous palliative pulmonary interventions, including pulmonary artery banding. Follow-up for all infants included periodic clinical examinations and echocardiography.

The repair surgery itself was customized for each patient. Depending on each infant's specific anatomy, the ventriculoseptal defect was repaired using direct suturing without a patch or using interposition of a small pericardial patch with a running suture. Closure of the atrioventricular cleft was with interrupted sutures, and closure of atrial defects was with a pericardial patch. Chi-square analysis and Fisher's exact test of the data showed no significant differences in postsurgical morbidity and mortality between the two treatment groups, Dr. Singh said. There were two deaths in the younger infants—one of which occurred during another noncardiac surgery—and one among the older group.

Morbidity related to the procedure was measured by the need for early reoperation (within 1 year) for residual ventriculoseptal defect or significant mitral regurgitation. “The reoperation rates were statistically identical, with three of the younger infants and four of the older ones requiring additional surgery within the first year,” said Dr. Singh. In addition, the number of infants in each group with mitral valve regurgitation, a common condition in this population, was similar, he said.

“Modern surgical techniques have essentially eliminated some of the problems previously associated with the surgical repair of CAVC, including postoperative pulmonary hypertension,” said Dr. Singh. “Today's procedure is associated with a high likelihood for success, and our findings suggest that such success is as likely in infants younger than 3 months than in older infants,” he said.

ORLANDO — Infants younger than 3 months who undergo repair of complete atrioventricular canal fare as well as older infants following the procedure, said Dr. R. Ramesh Singh at the annual meeting of the Southern Thoracic Surgical Association.

Numerous studies have shown that better outcomes are achieved when complete atrioventricular canal (CAVC) repair takes place within the first 6 months of life to prevent the development of heart failure and long-term pulmonary vascular changes resulting from a substantial increase in blood flow and pressure in the lung circulation. The demonstrated efficacy of CAVC surgical repair over the last 20 years—most notably a drop in mortality from about 25% to 3%—has led some surgical centers to adopt a more aggressive repair approach by operating on infants within the first 3 months of life, particularly in children with Down syndrome, who are more vulnerable to early pulmonary vascular changes than children without the condition, Dr. Singh said.

To determine whether the more aggressive approach is associated with increased morbidity or mortality, Dr. Singh and colleagues at the University of Virginia Health System, Charlottesville, reviewed the outcomes of 65 infants who underwent CAVC repair at their institution between 1990 and 2004. “The study was prompted in part by the difficulty thoracic surgery board examinees have had in dealing with this clinical scenario, simply because there is no consensus on the best timing of surgery,” said Dr. Singh.

Of the 65 infants, 26 underwent CAVC repair surgery on or before 3 months of age, and 39 had the procedure done after 3 months (mean age between 5 and 6 months). Other than age, characteristics of infants in both groups were similar, “although there was a significantly higher preponderance of patients with Down syndrome in the older group,” said Dr. Singh. “Down syndrome in itself is not an independent risk factor of [postsurgical] morbidity or mortality in this patient population,” he said.

All infants underwent preoperative echocardiography, and 13 of them—6 in the younger group, 7 in the older—also had cardiac catheterization evaluations. None of the patients had undergone previous palliative pulmonary interventions, including pulmonary artery banding. Follow-up for all infants included periodic clinical examinations and echocardiography.

The repair surgery itself was customized for each patient. Depending on each infant's specific anatomy, the ventriculoseptal defect was repaired using direct suturing without a patch or using interposition of a small pericardial patch with a running suture. Closure of the atrioventricular cleft was with interrupted sutures, and closure of atrial defects was with a pericardial patch. Chi-square analysis and Fisher's exact test of the data showed no significant differences in postsurgical morbidity and mortality between the two treatment groups, Dr. Singh said. There were two deaths in the younger infants—one of which occurred during another noncardiac surgery—and one among the older group.

Morbidity related to the procedure was measured by the need for early reoperation (within 1 year) for residual ventriculoseptal defect or significant mitral regurgitation. “The reoperation rates were statistically identical, with three of the younger infants and four of the older ones requiring additional surgery within the first year,” said Dr. Singh. In addition, the number of infants in each group with mitral valve regurgitation, a common condition in this population, was similar, he said.

“Modern surgical techniques have essentially eliminated some of the problems previously associated with the surgical repair of CAVC, including postoperative pulmonary hypertension,” said Dr. Singh. “Today's procedure is associated with a high likelihood for success, and our findings suggest that such success is as likely in infants younger than 3 months than in older infants,” he said.

ORLANDO — Infants younger than 3 months who undergo repair of complete atrioventricular canal fare as well as older infants following the procedure, said Dr. R. Ramesh Singh at the annual meeting of the Southern Thoracic Surgical Association.

Numerous studies have shown that better outcomes are achieved when complete atrioventricular canal (CAVC) repair takes place within the first 6 months of life to prevent the development of heart failure and long-term pulmonary vascular changes resulting from a substantial increase in blood flow and pressure in the lung circulation. The demonstrated efficacy of CAVC surgical repair over the last 20 years—most notably a drop in mortality from about 25% to 3%—has led some surgical centers to adopt a more aggressive repair approach by operating on infants within the first 3 months of life, particularly in children with Down syndrome, who are more vulnerable to early pulmonary vascular changes than children without the condition, Dr. Singh said.

To determine whether the more aggressive approach is associated with increased morbidity or mortality, Dr. Singh and colleagues at the University of Virginia Health System, Charlottesville, reviewed the outcomes of 65 infants who underwent CAVC repair at their institution between 1990 and 2004. “The study was prompted in part by the difficulty thoracic surgery board examinees have had in dealing with this clinical scenario, simply because there is no consensus on the best timing of surgery,” said Dr. Singh.

Of the 65 infants, 26 underwent CAVC repair surgery on or before 3 months of age, and 39 had the procedure done after 3 months (mean age between 5 and 6 months). Other than age, characteristics of infants in both groups were similar, “although there was a significantly higher preponderance of patients with Down syndrome in the older group,” said Dr. Singh. “Down syndrome in itself is not an independent risk factor of [postsurgical] morbidity or mortality in this patient population,” he said.

All infants underwent preoperative echocardiography, and 13 of them—6 in the younger group, 7 in the older—also had cardiac catheterization evaluations. None of the patients had undergone previous palliative pulmonary interventions, including pulmonary artery banding. Follow-up for all infants included periodic clinical examinations and echocardiography.

The repair surgery itself was customized for each patient. Depending on each infant's specific anatomy, the ventriculoseptal defect was repaired using direct suturing without a patch or using interposition of a small pericardial patch with a running suture. Closure of the atrioventricular cleft was with interrupted sutures, and closure of atrial defects was with a pericardial patch. Chi-square analysis and Fisher's exact test of the data showed no significant differences in postsurgical morbidity and mortality between the two treatment groups, Dr. Singh said. There were two deaths in the younger infants—one of which occurred during another noncardiac surgery—and one among the older group.

Morbidity related to the procedure was measured by the need for early reoperation (within 1 year) for residual ventriculoseptal defect or significant mitral regurgitation. “The reoperation rates were statistically identical, with three of the younger infants and four of the older ones requiring additional surgery within the first year,” said Dr. Singh. In addition, the number of infants in each group with mitral valve regurgitation, a common condition in this population, was similar, he said.

“Modern surgical techniques have essentially eliminated some of the problems previously associated with the surgical repair of CAVC, including postoperative pulmonary hypertension,” said Dr. Singh. “Today's procedure is associated with a high likelihood for success, and our findings suggest that such success is as likely in infants younger than 3 months than in older infants,” he said.

ORLANDO — Off-pump coronary artery revascularization surgery results in similar mortality but significantly less morbidity than on-pump procedures, said Dr. George Palmer at the annual meeting of the Southern Thoracic Surgical Association.

Using prospectively collected data for 1,208 consecutive patients who received coronary artery bypass grafts (CABGs) between February 2004 and July 2004, Dr. Palmer and colleagues in the multicenter Coronary Artery Revascularization Evaluation (CARE) study compared the outcomes of the 577 patients who had off-pump surgery and the 631 patients who had on-pump procedures. “The patients were not randomized. They were assigned to either off-pump or on-pump [by the respective surgeons],” said Dr. Palmer of Central Florida Regional Hospital in Sanford.

Data analysis using chi-squared statistics and t tests showed that patients in both study groups had similar predicted risks of mortality based on the Society of Thoracic Surgeons operative risk assessment model.

Preoperative medication use, including aspirin, β-blockers, ACE inhibitors, and inotropes, was similar in both groups. In terms of preoperative risk factors, there was no statistical difference between the two groups for mean age, gender, smoking, incidence of diabetes of renal failure, congestive heart failure, lung disease, myocardial infarction, or cerebrovascular disease.

There were statistical differences in the number of re-operations, with 38 in the on-pump group and 18 in the off-pump group, and in the ejection fraction, which measured 48.6% on pump and 51.0% off pump, though Dr. Palmer noted that the ejection fraction difference “was not likely of clinical significance.

There was no difference in operative mortality between the two groups, with rates of 1.7% and 1.9% for on-pump and off-pump, respectively, but on-pump procedures had statistically significant differences in rates of prolonged ventilation (9.8% vs. 3.1% for off-pump), atrial fibrillation (24.2% vs. 14.6%), blood product usage (50.6% vs. 34.2%), and renal failure (4.4% vs. 1.7%). The mean length of stay for on-pump surgery was 7.6 days, compared with 6.1 days for off-pump, Dr. Palmer said.

“These findings … suggest that off-pump coronary artery bypass surgery is a safe and less-expensive alternative to conventional CABG and may improve quality of life in some patients by reducing perioperative morbidity,” he said.

The CARE study is sponsored by HCA Inc., Guidant Corp., and Medtronic Inc.

ORLANDO — Off-pump coronary artery revascularization surgery results in similar mortality but significantly less morbidity than on-pump procedures, said Dr. George Palmer at the annual meeting of the Southern Thoracic Surgical Association.

Using prospectively collected data for 1,208 consecutive patients who received coronary artery bypass grafts (CABGs) between February 2004 and July 2004, Dr. Palmer and colleagues in the multicenter Coronary Artery Revascularization Evaluation (CARE) study compared the outcomes of the 577 patients who had off-pump surgery and the 631 patients who had on-pump procedures. “The patients were not randomized. They were assigned to either off-pump or on-pump [by the respective surgeons],” said Dr. Palmer of Central Florida Regional Hospital in Sanford.

Data analysis using chi-squared statistics and t tests showed that patients in both study groups had similar predicted risks of mortality based on the Society of Thoracic Surgeons operative risk assessment model.

Preoperative medication use, including aspirin, β-blockers, ACE inhibitors, and inotropes, was similar in both groups. In terms of preoperative risk factors, there was no statistical difference between the two groups for mean age, gender, smoking, incidence of diabetes of renal failure, congestive heart failure, lung disease, myocardial infarction, or cerebrovascular disease.

There were statistical differences in the number of re-operations, with 38 in the on-pump group and 18 in the off-pump group, and in the ejection fraction, which measured 48.6% on pump and 51.0% off pump, though Dr. Palmer noted that the ejection fraction difference “was not likely of clinical significance.

There was no difference in operative mortality between the two groups, with rates of 1.7% and 1.9% for on-pump and off-pump, respectively, but on-pump procedures had statistically significant differences in rates of prolonged ventilation (9.8% vs. 3.1% for off-pump), atrial fibrillation (24.2% vs. 14.6%), blood product usage (50.6% vs. 34.2%), and renal failure (4.4% vs. 1.7%). The mean length of stay for on-pump surgery was 7.6 days, compared with 6.1 days for off-pump, Dr. Palmer said.

“These findings … suggest that off-pump coronary artery bypass surgery is a safe and less-expensive alternative to conventional CABG and may improve quality of life in some patients by reducing perioperative morbidity,” he said.

The CARE study is sponsored by HCA Inc., Guidant Corp., and Medtronic Inc.

ORLANDO — Off-pump coronary artery revascularization surgery results in similar mortality but significantly less morbidity than on-pump procedures, said Dr. George Palmer at the annual meeting of the Southern Thoracic Surgical Association.

Using prospectively collected data for 1,208 consecutive patients who received coronary artery bypass grafts (CABGs) between February 2004 and July 2004, Dr. Palmer and colleagues in the multicenter Coronary Artery Revascularization Evaluation (CARE) study compared the outcomes of the 577 patients who had off-pump surgery and the 631 patients who had on-pump procedures. “The patients were not randomized. They were assigned to either off-pump or on-pump [by the respective surgeons],” said Dr. Palmer of Central Florida Regional Hospital in Sanford.

Data analysis using chi-squared statistics and t tests showed that patients in both study groups had similar predicted risks of mortality based on the Society of Thoracic Surgeons operative risk assessment model.

Preoperative medication use, including aspirin, β-blockers, ACE inhibitors, and inotropes, was similar in both groups. In terms of preoperative risk factors, there was no statistical difference between the two groups for mean age, gender, smoking, incidence of diabetes of renal failure, congestive heart failure, lung disease, myocardial infarction, or cerebrovascular disease.

There were statistical differences in the number of re-operations, with 38 in the on-pump group and 18 in the off-pump group, and in the ejection fraction, which measured 48.6% on pump and 51.0% off pump, though Dr. Palmer noted that the ejection fraction difference “was not likely of clinical significance.

There was no difference in operative mortality between the two groups, with rates of 1.7% and 1.9% for on-pump and off-pump, respectively, but on-pump procedures had statistically significant differences in rates of prolonged ventilation (9.8% vs. 3.1% for off-pump), atrial fibrillation (24.2% vs. 14.6%), blood product usage (50.6% vs. 34.2%), and renal failure (4.4% vs. 1.7%). The mean length of stay for on-pump surgery was 7.6 days, compared with 6.1 days for off-pump, Dr. Palmer said.

“These findings … suggest that off-pump coronary artery bypass surgery is a safe and less-expensive alternative to conventional CABG and may improve quality of life in some patients by reducing perioperative morbidity,” he said.

The CARE study is sponsored by HCA Inc., Guidant Corp., and Medtronic Inc.

CAMBRIDGE, MASS. — Infants with prolonged, unexplained fever and laboratory evidence of systemic inflammation should undergo echocardiography to look for coronary changes suggestive of Kawasaki disease, even if there are no other clinical signs of the generalized vasculitis, according to Dr. Marisol Figueira.

“The manifestations of Kawasaki disease in infants are often subtle, and many times infants with the condition do not meet the full diagnostic criteria,” Dr. Figueira said at a conference on pediatric infectious diseases.

Typically, a diagnosis of Kawasaki disease requires the presence of unexplained fever and the presence of at least four of the following five principal features: changes in the extremities such as redness, swelling, induration of the hands and feet, and, later, peeling of the fingers and toes; polymorphic rash involving the trunk and extremities; nonexudative conjunctivitis; redness and swelling of the lips and oral cavity; and cervical adenitis.

Associated laboratory findings often include elevated erythrocyte sedimentation rate and C-reactive protein levels in the acute phase, and may include any of several nonspecific findings, such as neutrophilia, mild anemia, hypoalbuminemia, elevated serum immunoglobulin E levels, thrombocytosis, proteinuria, and sterile pyuria, said Dr. Figueira of Boston University Medical Center.

Infants with Kawasaki disease—particularly those younger than 6 months—may present with only unexplained fever, or the fever may be accompanied by only two or three of the clinical features of classic Kawasaki disease. In fact, reported Dr. Figueira, “such cases of incomplete or atypical Kawasaki disease, in which patients have fewer than four of the five principal features, have been increasingly reported in infants.”

Recognizing incomplete Kawasaki disease in infants is particularly challenging, because the clinical features that do present in this population tend to be more subtle than those seen in older children and are often mistaken for symptoms of other conditions, Dr. Figueira said at the conference, which was sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

For example, “an infant with fever, rash, and cerebral spinal fluid pleocytosis may be misdiagnosed with viral meningitis. The presence of rash and mucosal changes that follow often are mistaken for a reaction to antibiotics administered for presumed bacterial lymphadenitis, and sterile pyuria may be mistaken for a partially treated urinary tract infection,” she said.

To avoid misdiagnosis, physicians should make Kawasaki disease part of the differential diagnosis for all infants with unexplained prolonged fever and any of the characteristics consistent with the condition, Dr. Figueira said. In such patients, she noted, “laboratory values, particularly for the acute phase reactants, should be obtained.”

If these values are elevated—a C-reactive protein measure of 3 mg/dL or higher and an erythrocyte sedimentation rate greater than 40 mm/hour—an echocardiogram should be obtained to check for coronary changes that might indicate Kawasaki disease, Dr. Figueira said.

“Although aneurysms rarely form before day 10 of illness, perivascular brightness, ectasia, and lack of tapering of the coronary arteries can be seen in the acute stage of the disease,” she said. Other potential findings include decreased left ventricular contractility, mild valvular regurgitation, and pericardial effusion.

If an echocardiograph is positive for these changes, treatment for Kawasaki disease, which generally includes intravenous immunoglobulin and aspirin therapy, should begin immediately to preclude long-term, permanent coronary damage, Dr. Figueira said.

“If the echo is negative but the fever or any symptoms continue to persist, a repeat echo consult may be needed.”

CAMBRIDGE, MASS. — Infants with prolonged, unexplained fever and laboratory evidence of systemic inflammation should undergo echocardiography to look for coronary changes suggestive of Kawasaki disease, even if there are no other clinical signs of the generalized vasculitis, according to Dr. Marisol Figueira.

“The manifestations of Kawasaki disease in infants are often subtle, and many times infants with the condition do not meet the full diagnostic criteria,” Dr. Figueira said at a conference on pediatric infectious diseases.

Typically, a diagnosis of Kawasaki disease requires the presence of unexplained fever and the presence of at least four of the following five principal features: changes in the extremities such as redness, swelling, induration of the hands and feet, and, later, peeling of the fingers and toes; polymorphic rash involving the trunk and extremities; nonexudative conjunctivitis; redness and swelling of the lips and oral cavity; and cervical adenitis.

Associated laboratory findings often include elevated erythrocyte sedimentation rate and C-reactive protein levels in the acute phase, and may include any of several nonspecific findings, such as neutrophilia, mild anemia, hypoalbuminemia, elevated serum immunoglobulin E levels, thrombocytosis, proteinuria, and sterile pyuria, said Dr. Figueira of Boston University Medical Center.

Infants with Kawasaki disease—particularly those younger than 6 months—may present with only unexplained fever, or the fever may be accompanied by only two or three of the clinical features of classic Kawasaki disease. In fact, reported Dr. Figueira, “such cases of incomplete or atypical Kawasaki disease, in which patients have fewer than four of the five principal features, have been increasingly reported in infants.”

Recognizing incomplete Kawasaki disease in infants is particularly challenging, because the clinical features that do present in this population tend to be more subtle than those seen in older children and are often mistaken for symptoms of other conditions, Dr. Figueira said at the conference, which was sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

For example, “an infant with fever, rash, and cerebral spinal fluid pleocytosis may be misdiagnosed with viral meningitis. The presence of rash and mucosal changes that follow often are mistaken for a reaction to antibiotics administered for presumed bacterial lymphadenitis, and sterile pyuria may be mistaken for a partially treated urinary tract infection,” she said.

To avoid misdiagnosis, physicians should make Kawasaki disease part of the differential diagnosis for all infants with unexplained prolonged fever and any of the characteristics consistent with the condition, Dr. Figueira said. In such patients, she noted, “laboratory values, particularly for the acute phase reactants, should be obtained.”

If these values are elevated—a C-reactive protein measure of 3 mg/dL or higher and an erythrocyte sedimentation rate greater than 40 mm/hour—an echocardiogram should be obtained to check for coronary changes that might indicate Kawasaki disease, Dr. Figueira said.

“Although aneurysms rarely form before day 10 of illness, perivascular brightness, ectasia, and lack of tapering of the coronary arteries can be seen in the acute stage of the disease,” she said. Other potential findings include decreased left ventricular contractility, mild valvular regurgitation, and pericardial effusion.

If an echocardiograph is positive for these changes, treatment for Kawasaki disease, which generally includes intravenous immunoglobulin and aspirin therapy, should begin immediately to preclude long-term, permanent coronary damage, Dr. Figueira said.

“If the echo is negative but the fever or any symptoms continue to persist, a repeat echo consult may be needed.”

CAMBRIDGE, MASS. — Infants with prolonged, unexplained fever and laboratory evidence of systemic inflammation should undergo echocardiography to look for coronary changes suggestive of Kawasaki disease, even if there are no other clinical signs of the generalized vasculitis, according to Dr. Marisol Figueira.

“The manifestations of Kawasaki disease in infants are often subtle, and many times infants with the condition do not meet the full diagnostic criteria,” Dr. Figueira said at a conference on pediatric infectious diseases.

Typically, a diagnosis of Kawasaki disease requires the presence of unexplained fever and the presence of at least four of the following five principal features: changes in the extremities such as redness, swelling, induration of the hands and feet, and, later, peeling of the fingers and toes; polymorphic rash involving the trunk and extremities; nonexudative conjunctivitis; redness and swelling of the lips and oral cavity; and cervical adenitis.

Associated laboratory findings often include elevated erythrocyte sedimentation rate and C-reactive protein levels in the acute phase, and may include any of several nonspecific findings, such as neutrophilia, mild anemia, hypoalbuminemia, elevated serum immunoglobulin E levels, thrombocytosis, proteinuria, and sterile pyuria, said Dr. Figueira of Boston University Medical Center.

Infants with Kawasaki disease—particularly those younger than 6 months—may present with only unexplained fever, or the fever may be accompanied by only two or three of the clinical features of classic Kawasaki disease. In fact, reported Dr. Figueira, “such cases of incomplete or atypical Kawasaki disease, in which patients have fewer than four of the five principal features, have been increasingly reported in infants.”

Recognizing incomplete Kawasaki disease in infants is particularly challenging, because the clinical features that do present in this population tend to be more subtle than those seen in older children and are often mistaken for symptoms of other conditions, Dr. Figueira said at the conference, which was sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

For example, “an infant with fever, rash, and cerebral spinal fluid pleocytosis may be misdiagnosed with viral meningitis. The presence of rash and mucosal changes that follow often are mistaken for a reaction to antibiotics administered for presumed bacterial lymphadenitis, and sterile pyuria may be mistaken for a partially treated urinary tract infection,” she said.

To avoid misdiagnosis, physicians should make Kawasaki disease part of the differential diagnosis for all infants with unexplained prolonged fever and any of the characteristics consistent with the condition, Dr. Figueira said. In such patients, she noted, “laboratory values, particularly for the acute phase reactants, should be obtained.”

If these values are elevated—a C-reactive protein measure of 3 mg/dL or higher and an erythrocyte sedimentation rate greater than 40 mm/hour—an echocardiogram should be obtained to check for coronary changes that might indicate Kawasaki disease, Dr. Figueira said.

“Although aneurysms rarely form before day 10 of illness, perivascular brightness, ectasia, and lack of tapering of the coronary arteries can be seen in the acute stage of the disease,” she said. Other potential findings include decreased left ventricular contractility, mild valvular regurgitation, and pericardial effusion.

If an echocardiograph is positive for these changes, treatment for Kawasaki disease, which generally includes intravenous immunoglobulin and aspirin therapy, should begin immediately to preclude long-term, permanent coronary damage, Dr. Figueira said.

“If the echo is negative but the fever or any symptoms continue to persist, a repeat echo consult may be needed.”

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occur in children younger than 5 years of age.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs. “Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity.”

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said. Because meningococcal disease can be a serious, rapidly progressive infection leaving little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose, often presenting with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, added Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome may cause some hesitation about vaccination among some parents. “Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

The majority of meningococcal disease cases that occur in adolescents are potentially vaccine preventable. DR. JACOBS

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occur in children younger than 5 years of age.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs. “Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity.”

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said. Because meningococcal disease can be a serious, rapidly progressive infection leaving little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose, often presenting with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, added Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome may cause some hesitation about vaccination among some parents. “Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

The majority of meningococcal disease cases that occur in adolescents are potentially vaccine preventable. DR. JACOBS

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occur in children younger than 5 years of age.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs. “Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity.”

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said. Because meningococcal disease can be a serious, rapidly progressive infection leaving little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose, often presenting with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, added Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome may cause some hesitation about vaccination among some parents. “Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

The majority of meningococcal disease cases that occur in adolescents are potentially vaccine preventable. DR. JACOBS

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occurs in children younger than 5 years of age, with a peak incidence in those younger than 2 years old.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs.

“Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity,” he said.

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said.

Because meningococcal disease can be a serious, rapidly progressive infection that leaves little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose because it often presents with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, said Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according to the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome, a serious nervous system disorder, may cause some hesitation about vaccination among some parents.

“Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occurs in children younger than 5 years of age, with a peak incidence in those younger than 2 years old.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs.

“Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity,” he said.

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said.

Because meningococcal disease can be a serious, rapidly progressive infection that leaves little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose because it often presents with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, said Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according to the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome, a serious nervous system disorder, may cause some hesitation about vaccination among some parents.

“Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

CAMBRIDGE, MASS. — Although adolescents are not the pediatric population at greatest risk for invasive meningococcal disease, advocating the use of the conjugate meningococcal vaccine in this patient population “makes perfect sense,” said Dr. Richard F. Jacobs, the Horace C. Cabe Professor of Pediatrics at the University of Arkansas, Little Rock.

That population still is at risk, although the majority of meningococcal infections occurs in children younger than 5 years of age, with a peak incidence in those younger than 2 years old.

“Ideally, we would like a conjugated vaccine against bacterial meningitis that we would use as an infant strategy in the first 6 months, with a booster dose at 1 year, that would have the same effect as the Haemophilus influenzae type b and pneumococcal conjugate vaccines, but the conjugated vaccine that is available does not target the Neisseria meningitidis serogroup responsible for the majority of meningococcal disease in this population,” Dr. Jacobs said at a conference on pediatric infectious diseases sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

According to the Centers for Disease Control and Prevention, fewer than half of all cases of meningococcal disease in children younger than 5 years are potentially vaccine preventable because they are caused by N. meningitidis serogroup B.

“The quadrivalent vaccines in this country [nonconjugated MPSV4 and conjugated MCV4] cover serogroups A, C, Y, and W-135,” said Dr. Jacobs.

“Serogroup B was only sequenced within the last 3 years. It has a different outer membrane than the other serogroups, and it has multiple subtypes, making it difficult to develop a vaccine that provides protective immunity,” he said.

In contrast, the majority of cases of meningococcal disease that occur in adolescents and young adults—most often caused by serogroups C and Y—are potentially vaccine preventable.

This age group is also especially likely to engage in behaviors that could put them at increased risk for infection. “A number of studies have identified cigarette smoking, alcohol consumption, and bar patronage as risk factors for meningococcal disease,” said Dr. Jacobs.

Together with the fact that these populations are more likely to be living in close contact with each other at school or in dormitories, the risk of becoming infected and spreading infection is substantial, he said.

Because meningococcal disease can be a serious, rapidly progressive infection that leaves little time for diagnosis and treatment, and because early meningococcal disease can be difficult to diagnose because it often presents with symptoms similar to those of common viral illnesses, prevention wherever possible should be the order of the day, said Dr. Jacobs.

“The American Academy of Pediatrics has been advocating the adolescent health visit for children who are 11–12 years old, and it makes sense to include the conjugate meningococcal vaccine in that visit,” Dr. Jacobs said. “The visit is important, according to the AAP, not only for the meningococcal vaccine, but also for the pertussis booster, for the varicella vaccine in kids who never received it or who never had chicken pox, and for kids who never got their second MMR.

“The timing is also right because it is at this visit that the AAP recommends discussions of such issues as sexuality, teen pregnancy, smoking, drinking, and drugs—all behaviors that could contribute to increased risk of spreading infection,” he said.

Recent reports linking the MPV4 (Menactra) vaccine to Guillain-Barré syndrome, a serious nervous system disorder, may cause some hesitation about vaccination among some parents.

“Even though there is not enough evidence to substantiate the link, some parents will express concern and may refuse the vaccination,” said Dr. Jacobs. “Advise these parents that the nonconjugated vaccine, which has not been associated with Guillain-Barré, can also provide protection, although the protection is not expected to last as long as that offered by Menactra.”

ATLANTA – Adolescents with prodromal psychosis who were being treated with second-generation antipsychotic drugs had significantly higher rates of medication noncompliance than adolescents who had the same early symptoms and were taking antidepressants, according to early results from a naturalistic treatment study.

Preliminary findings from the ongoing Recognition and Prevention (RAP) program at the Zucker Hillside Hospital in Glen Oaks, N.Y., and Schneider Children's Hospital in New Hyde Park, N.Y., also showed that the medication-noncompliant adolescents were 10 times more likely to convert to full psychosis during a 5-year follow-up period than adolescents who remained on their prescribed regimen, Barbara Cornblatt, Ph.D., said at the annual meeting of the American Psychiatric Association.

“While the second-generation antipsychotics may have a positive effect in treating symptoms, if adolescents won't stay on them, the drugs cannot possibly be effective,” said Dr. Cornblatt, director of the RAP program.

“On the other hand, it seems that the antidepressants are more tolerated and have some kind of protective effect, though exactly what that may be is not yet clear,” she said.

The RAP program began in 1997 and typically serves adolescents between the ages of 12 and 18 who fall somewhere on the prodromal psychosis continuum and have been referred to the stand-alone RAP clinic for treatment.

The objective of the research arm of the RAP program is to gain insight into the natural history and developmental course of psychotic disorders, as well as to understand the effects of different medications at different phases of the illness using a naturalistic vs. randomized control format.

“Our researchers treat patients as they would if they were in private practice with respect to selecting drug and behavior therapy. We give them no input; there's no ideation of our hypotheses. When they prescribe medication, it's based on the symptoms being displayed, not the notion of prevention,” Dr. Cornblatt said.

To date, 152 patients at a mean age of 15 years have completed the baseline research procedures and have been divided into one of three subgroups:

▸ Clinical high-risk negative patients, who meet prodromal criteria but have only exhibited nonspecific negative symptoms, such as anhedonia and lack of affect.

▸ Clinical high-risk positive patients, who have attenuated positive prodromal symptoms (delusions and hallucinations, as well as disorganized thoughts and speech).

▸ Clinical high-risk “slip” patients, “who are just slipping into first-episode psychosis,” Dr. Cornblatt explained.

The adherence/conversion data come from a sample of 50 clinical high-risk positive patients who had at least 1 year of follow-up and available adherence rates. Although no significant differences were found in baseline symptoms, 22 of the patients were prescribed antidepressants, 11 received monotherapy with second-generation antipsychotics (either olanzapine or risperidone), and 17 received combination therapy of antidepressants and antipsychotics.

“For purposes of reporting outcome, the two groups that received antipsychotic medications were combined because we didn't find any difference between the baseline characteristics or outcome between combination [and] monotherapy,” Dr. Cornblatt said.

During the follow-up period, investigators found that 13 of the 50 patients developed psychoses. Of the 13 who converted, 12 were receiving antipsychotic medication.

“In other words, nearly half the patients being treated with antipsychotics converted, compared with 1 out of 22 patients on antidepressants,” Dr. Cornblatt noted.

The only major difference that was noted between these two groups, other than the class of medication they received, was noncompliance to medication. Approximately 64% of adolescents prescribed antipsychotics were noncompliant, compared with 18% of those prescribed antidepressants alone.

“In general, the females in the study were more compliant with medication, and the older boys were the least compliant, suggesting that the earlier therapy is introduced, the more successful it might be,” Dr. Cornblatt said.

The low conversion rate in this study among those adolescents who stayed on their antidepressant medication and the high conversion rate among those who were medication noncompliant generate several hypotheses.

“It's possible that the negative symptoms set up some sort of biologic vulnerability, and maybe going to antidepressants directly affects these underlying negative components,” Dr. Cornblatt said.

“It's also possible that, although noncompliance doesn't cause positive symptoms, it could act as a trigger that makes them worse or more likely to progress to psychosis,” she said.

Although the outcome data from this investigation are “obviously not the final word because the study was not randomized, it does make the case that treating prodromal individuals with antidepressants does not cause any damage and might have some kind of positive effect,” she said.

“And it also points to medication noncompliance as a possible stressor, and one that we might be able to deal with,” Dr. Cornblatt noted.

'It seems that the antidepressants are more tolerated and have some kind of protective effect.' DR. CORNBLATT

ATLANTA – Adolescents with prodromal psychosis who were being treated with second-generation antipsychotic drugs had significantly higher rates of medication noncompliance than adolescents who had the same early symptoms and were taking antidepressants, according to early results from a naturalistic treatment study.

Preliminary findings from the ongoing Recognition and Prevention (RAP) program at the Zucker Hillside Hospital in Glen Oaks, N.Y., and Schneider Children's Hospital in New Hyde Park, N.Y., also showed that the medication-noncompliant adolescents were 10 times more likely to convert to full psychosis during a 5-year follow-up period than adolescents who remained on their prescribed regimen, Barbara Cornblatt, Ph.D., said at the annual meeting of the American Psychiatric Association.

“While the second-generation antipsychotics may have a positive effect in treating symptoms, if adolescents won't stay on them, the drugs cannot possibly be effective,” said Dr. Cornblatt, director of the RAP program.

“On the other hand, it seems that the antidepressants are more tolerated and have some kind of protective effect, though exactly what that may be is not yet clear,” she said.

The RAP program began in 1997 and typically serves adolescents between the ages of 12 and 18 who fall somewhere on the prodromal psychosis continuum and have been referred to the stand-alone RAP clinic for treatment.

The objective of the research arm of the RAP program is to gain insight into the natural history and developmental course of psychotic disorders, as well as to understand the effects of different medications at different phases of the illness using a naturalistic vs. randomized control format.

“Our researchers treat patients as they would if they were in private practice with respect to selecting drug and behavior therapy. We give them no input; there's no ideation of our hypotheses. When they prescribe medication, it's based on the symptoms being displayed, not the notion of prevention,” Dr. Cornblatt said.

To date, 152 patients at a mean age of 15 years have completed the baseline research procedures and have been divided into one of three subgroups:

▸ Clinical high-risk negative patients, who meet prodromal criteria but have only exhibited nonspecific negative symptoms, such as anhedonia and lack of affect.

▸ Clinical high-risk positive patients, who have attenuated positive prodromal symptoms (delusions and hallucinations, as well as disorganized thoughts and speech).

▸ Clinical high-risk “slip” patients, “who are just slipping into first-episode psychosis,” Dr. Cornblatt explained.

The adherence/conversion data come from a sample of 50 clinical high-risk positive patients who had at least 1 year of follow-up and available adherence rates. Although no significant differences were found in baseline symptoms, 22 of the patients were prescribed antidepressants, 11 received monotherapy with second-generation antipsychotics (either olanzapine or risperidone), and 17 received combination therapy of antidepressants and antipsychotics.

“For purposes of reporting outcome, the two groups that received antipsychotic medications were combined because we didn't find any difference between the baseline characteristics or outcome between combination [and] monotherapy,” Dr. Cornblatt said.

During the follow-up period, investigators found that 13 of the 50 patients developed psychoses. Of the 13 who converted, 12 were receiving antipsychotic medication.

“In other words, nearly half the patients being treated with antipsychotics converted, compared with 1 out of 22 patients on antidepressants,” Dr. Cornblatt noted.

The only major difference that was noted between these two groups, other than the class of medication they received, was noncompliance to medication. Approximately 64% of adolescents prescribed antipsychotics were noncompliant, compared with 18% of those prescribed antidepressants alone.

“In general, the females in the study were more compliant with medication, and the older boys were the least compliant, suggesting that the earlier therapy is introduced, the more successful it might be,” Dr. Cornblatt said.

The low conversion rate in this study among those adolescents who stayed on their antidepressant medication and the high conversion rate among those who were medication noncompliant generate several hypotheses.

“It's possible that the negative symptoms set up some sort of biologic vulnerability, and maybe going to antidepressants directly affects these underlying negative components,” Dr. Cornblatt said.

“It's also possible that, although noncompliance doesn't cause positive symptoms, it could act as a trigger that makes them worse or more likely to progress to psychosis,” she said.

Although the outcome data from this investigation are “obviously not the final word because the study was not randomized, it does make the case that treating prodromal individuals with antidepressants does not cause any damage and might have some kind of positive effect,” she said.

“And it also points to medication noncompliance as a possible stressor, and one that we might be able to deal with,” Dr. Cornblatt noted.

'It seems that the antidepressants are more tolerated and have some kind of protective effect.' DR. CORNBLATT

ATLANTA – Adolescents with prodromal psychosis who were being treated with second-generation antipsychotic drugs had significantly higher rates of medication noncompliance than adolescents who had the same early symptoms and were taking antidepressants, according to early results from a naturalistic treatment study.

Preliminary findings from the ongoing Recognition and Prevention (RAP) program at the Zucker Hillside Hospital in Glen Oaks, N.Y., and Schneider Children's Hospital in New Hyde Park, N.Y., also showed that the medication-noncompliant adolescents were 10 times more likely to convert to full psychosis during a 5-year follow-up period than adolescents who remained on their prescribed regimen, Barbara Cornblatt, Ph.D., said at the annual meeting of the American Psychiatric Association.

“While the second-generation antipsychotics may have a positive effect in treating symptoms, if adolescents won't stay on them, the drugs cannot possibly be effective,” said Dr. Cornblatt, director of the RAP program.

“On the other hand, it seems that the antidepressants are more tolerated and have some kind of protective effect, though exactly what that may be is not yet clear,” she said.

The RAP program began in 1997 and typically serves adolescents between the ages of 12 and 18 who fall somewhere on the prodromal psychosis continuum and have been referred to the stand-alone RAP clinic for treatment.

The objective of the research arm of the RAP program is to gain insight into the natural history and developmental course of psychotic disorders, as well as to understand the effects of different medications at different phases of the illness using a naturalistic vs. randomized control format.

“Our researchers treat patients as they would if they were in private practice with respect to selecting drug and behavior therapy. We give them no input; there's no ideation of our hypotheses. When they prescribe medication, it's based on the symptoms being displayed, not the notion of prevention,” Dr. Cornblatt said.

To date, 152 patients at a mean age of 15 years have completed the baseline research procedures and have been divided into one of three subgroups:

▸ Clinical high-risk negative patients, who meet prodromal criteria but have only exhibited nonspecific negative symptoms, such as anhedonia and lack of affect.

▸ Clinical high-risk positive patients, who have attenuated positive prodromal symptoms (delusions and hallucinations, as well as disorganized thoughts and speech).

▸ Clinical high-risk “slip” patients, “who are just slipping into first-episode psychosis,” Dr. Cornblatt explained.

The adherence/conversion data come from a sample of 50 clinical high-risk positive patients who had at least 1 year of follow-up and available adherence rates. Although no significant differences were found in baseline symptoms, 22 of the patients were prescribed antidepressants, 11 received monotherapy with second-generation antipsychotics (either olanzapine or risperidone), and 17 received combination therapy of antidepressants and antipsychotics.

“For purposes of reporting outcome, the two groups that received antipsychotic medications were combined because we didn't find any difference between the baseline characteristics or outcome between combination [and] monotherapy,” Dr. Cornblatt said.

During the follow-up period, investigators found that 13 of the 50 patients developed psychoses. Of the 13 who converted, 12 were receiving antipsychotic medication.

“In other words, nearly half the patients being treated with antipsychotics converted, compared with 1 out of 22 patients on antidepressants,” Dr. Cornblatt noted.

The only major difference that was noted between these two groups, other than the class of medication they received, was noncompliance to medication. Approximately 64% of adolescents prescribed antipsychotics were noncompliant, compared with 18% of those prescribed antidepressants alone.

“In general, the females in the study were more compliant with medication, and the older boys were the least compliant, suggesting that the earlier therapy is introduced, the more successful it might be,” Dr. Cornblatt said.

The low conversion rate in this study among those adolescents who stayed on their antidepressant medication and the high conversion rate among those who were medication noncompliant generate several hypotheses.

“It's possible that the negative symptoms set up some sort of biologic vulnerability, and maybe going to antidepressants directly affects these underlying negative components,” Dr. Cornblatt said.

“It's also possible that, although noncompliance doesn't cause positive symptoms, it could act as a trigger that makes them worse or more likely to progress to psychosis,” she said.

Although the outcome data from this investigation are “obviously not the final word because the study was not randomized, it does make the case that treating prodromal individuals with antidepressants does not cause any damage and might have some kind of positive effect,” she said.

“And it also points to medication noncompliance as a possible stressor, and one that we might be able to deal with,” Dr. Cornblatt noted.

'It seems that the antidepressants are more tolerated and have some kind of protective effect.' DR. CORNBLATT

LOS ANGELES — Children with treated epilepsy show significant osteopenia, placing them at high risk for pathological fractures, early results from an ongoing prospective study have shown.

The findings suggest that epilepsy and/or its treatment either induce accelerated bone loss or are primary determinants of failure to accrue normal bone mineral density, according to Dr. Marc K. Drezner, a professor of medicine at the University of Wisconsin, Madison.

While older patients with treated epilepsy have osteopenia and pathologic fractures at a significantly higher rate than the general population, controversy exists over whether the osteopathy results from epilepsy and its treatments or reflects age-dependent bone disease, Dr. Drezner said in a poster presentation at the annual meeting of the Child Neurology Society.

Dr. Drezner and his associates compared age-normalized total body bone mineral density (BMD) z scores of 8- to 18-year-old patients with treated epilepsy and healthy controls, excluding epilepsy patients who were non-ambulatory, had chronic diseases other than epilepsy, or were taking medications with known adverse bone effects.

The investigation included 34 treated epilepsy patients and 24 healthy controls (mean age 13) with comparable gender and weight distributions, calcium intake, and activity levels.

The mean BMD z scores were −0.31 for the epilepsy patients and 0.71 for the control group, a statistically significant difference, Dr. Drezner stated. Of the 34 epilepsy patients, 8 had BMD measures more than one standard deviation below normal, indicating osteopenia, while none of the healthy controls had osteopenic measures. Also, 8 of the control patients had BMD measures more than one standard deviation above normal, compared with only 5 of the epilepsy patients.

This study, which is still enrolling patients, is supported by a grant from GlaxoSmithKline.

LOS ANGELES — Children with treated epilepsy show significant osteopenia, placing them at high risk for pathological fractures, early results from an ongoing prospective study have shown.

The findings suggest that epilepsy and/or its treatment either induce accelerated bone loss or are primary determinants of failure to accrue normal bone mineral density, according to Dr. Marc K. Drezner, a professor of medicine at the University of Wisconsin, Madison.

While older patients with treated epilepsy have osteopenia and pathologic fractures at a significantly higher rate than the general population, controversy exists over whether the osteopathy results from epilepsy and its treatments or reflects age-dependent bone disease, Dr. Drezner said in a poster presentation at the annual meeting of the Child Neurology Society.

Dr. Drezner and his associates compared age-normalized total body bone mineral density (BMD) z scores of 8- to 18-year-old patients with treated epilepsy and healthy controls, excluding epilepsy patients who were non-ambulatory, had chronic diseases other than epilepsy, or were taking medications with known adverse bone effects.

The investigation included 34 treated epilepsy patients and 24 healthy controls (mean age 13) with comparable gender and weight distributions, calcium intake, and activity levels.

The mean BMD z scores were −0.31 for the epilepsy patients and 0.71 for the control group, a statistically significant difference, Dr. Drezner stated. Of the 34 epilepsy patients, 8 had BMD measures more than one standard deviation below normal, indicating osteopenia, while none of the healthy controls had osteopenic measures. Also, 8 of the control patients had BMD measures more than one standard deviation above normal, compared with only 5 of the epilepsy patients.

This study, which is still enrolling patients, is supported by a grant from GlaxoSmithKline.

LOS ANGELES — Children with treated epilepsy show significant osteopenia, placing them at high risk for pathological fractures, early results from an ongoing prospective study have shown.

The findings suggest that epilepsy and/or its treatment either induce accelerated bone loss or are primary determinants of failure to accrue normal bone mineral density, according to Dr. Marc K. Drezner, a professor of medicine at the University of Wisconsin, Madison.

While older patients with treated epilepsy have osteopenia and pathologic fractures at a significantly higher rate than the general population, controversy exists over whether the osteopathy results from epilepsy and its treatments or reflects age-dependent bone disease, Dr. Drezner said in a poster presentation at the annual meeting of the Child Neurology Society.

Dr. Drezner and his associates compared age-normalized total body bone mineral density (BMD) z scores of 8- to 18-year-old patients with treated epilepsy and healthy controls, excluding epilepsy patients who were non-ambulatory, had chronic diseases other than epilepsy, or were taking medications with known adverse bone effects.

The investigation included 34 treated epilepsy patients and 24 healthy controls (mean age 13) with comparable gender and weight distributions, calcium intake, and activity levels.

The mean BMD z scores were −0.31 for the epilepsy patients and 0.71 for the control group, a statistically significant difference, Dr. Drezner stated. Of the 34 epilepsy patients, 8 had BMD measures more than one standard deviation below normal, indicating osteopenia, while none of the healthy controls had osteopenic measures. Also, 8 of the control patients had BMD measures more than one standard deviation above normal, compared with only 5 of the epilepsy patients.

This study, which is still enrolling patients, is supported by a grant from GlaxoSmithKline.

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Michael Pichichero, M.D., said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” Dr. Pichichero said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

One way to gauge the performance of rapid strep tests is “to look at your own practice,” he suggested. “Take a look at the last hundred negative rapid tests performed in your office. If the follow-up cultures for 90 or more of them are negative, that should tell you that, for the patients you're testing and the way you're using the tests, you can probably stop the follow-up cultures.”

'First you have to know who you are culturing. We only culture patients who we think have strep.' DR. PICHICHERO

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Michael Pichichero, M.D., said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” Dr. Pichichero said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

One way to gauge the performance of rapid strep tests is “to look at your own practice,” he suggested. “Take a look at the last hundred negative rapid tests performed in your office. If the follow-up cultures for 90 or more of them are negative, that should tell you that, for the patients you're testing and the way you're using the tests, you can probably stop the follow-up cultures.”

'First you have to know who you are culturing. We only culture patients who we think have strep.' DR. PICHICHERO

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Michael Pichichero, M.D., said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” Dr. Pichichero said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

One way to gauge the performance of rapid strep tests is “to look at your own practice,” he suggested. “Take a look at the last hundred negative rapid tests performed in your office. If the follow-up cultures for 90 or more of them are negative, that should tell you that, for the patients you're testing and the way you're using the tests, you can probably stop the follow-up cultures.”

'First you have to know who you are culturing. We only culture patients who we think have strep.' DR. PICHICHERO

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Dr. Michael Pichichero said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” he said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

'Only 2% of the patients with negative rapid tests cultured positive on follow-up.' DR. PICHICHERO

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Dr. Michael Pichichero said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” he said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

'Only 2% of the patients with negative rapid tests cultured positive on follow-up.' DR. PICHICHERO

CAMBRIDGE, MASS. — Backup throat cultures following negative rapid group A strep detection tests may no longer be necessary in some practices, Dr. Michael Pichichero said at a conference on pediatric infectious diseases.

To determine whether the standard procedure can be discontinued, clinicians can undertake a simple investigation to assess the sensitivity of commercial rapid immunochemical antigen test kits as they are used in their practices, Dr. Pichichero suggested at the conference, sponsored by Boston University, PEDIATRIC NEWS, and FAMILY PRACTICE NEWS.

“In the early 1990s, published studies evaluating the accuracy of rapid strep tests, compared with throat culture, suggested the rapid tests had really good specificity, but the sensitivity in the clinical setting of office-based practices wasn't there,” said Dr. Pichichero of the University of Rochester (N.Y.) Medical Center.

Because of the sensitivity limitations, the American Academy of Pediatrics recommended in its 2000 Red Book—and continues to recommend—that all negative rapid diagnostic tests for group A strep pharyngitis be backed up by throat culture.

Because of the very high specificity of the rapid tests, a positive test result does not require throat culture confirmation, noted Dr. Pichichero, who is also in private practice in Rochester.

Since the early 1990s, the rapid strep tests have matured and new products have emerged, “and at some point it seemed to us that the sensitivity was getting better too,” Dr. Pichichero said.

To test this hypothesis, Dr. Pichichero and his colleagues conducted a retrospective analysis reviewing 11,427 of the rapid group A strep tests performed in their practice between January 1996 and June 1999.

Of the 11,427 tests, 8,385 were negative and 3,042 were positive. Patients testing positive began antibiotic treatment immediately. Nearly all of the patients testing negative—8,234 of 8,385, or 98%—received backup cultures.

“Only 2% of the patients with negative rapid tests cultured positive on follow-up. You can't expect much better sensitivity than that, even with throat culture,” he said.

The findings cannot necessarily be generalized across practices, however. “There are some important considerations. First, you have to know who you're culturing. We only culture patients who we think have strep. If you culture patients with upper respiratory infections, for example, you're going to have more issues,” Dr. Pichichero said. “The other important thing is, you have got to use a good test, and a good test is probably not one that costs less than a dollar. You're going to have to spend about $1.50-$2.00—well worth the expense if the return is good sensitivity and a reduction in the costs associated with cultures.”

'Only 2% of the patients with negative rapid tests cultured positive on follow-up.' DR. PICHICHERO