Heidi Splete

PHOENIX — Radioimmunotherapy has the potential to prolong survival in patients with advanced medullary thyroid carcinoma, based on data from a small but promising study presented at the annual meeting of the American Thyroid Association.

Medullary thyroid carcinoma (MTC) differs from other solid tumors in that it progresses slowly when untreated, so even a slight treatment impact may have a large payoff in terms of months of life gained.

Dr. Stéphane Bardet, head of the nuclear medicine department at the Centre François Baclesse, in Caen, France, presented findings from a study published earlier this year in the April issue of the Journal of Clinical Oncology in which the use of pretargeted anticarcinoembryonic antigen (anti-CEA) radioimmunotherapy (RIT) successfully detected malignant lesions and resulted in a higher dose of radiation to tumor cells (J. Clin. Oncol. 2006;24:1705–11).

Radioactive iodine therapy is often used to destroy remaining thyroid tissue after thyroid cancer surgery. RIT includes an antibody, as well as the iodine, that works to target the cancerous tissue more effectively than iodine alone. “It's important to identify high-risk patients who need to be treated after surgery as early as possible, versus low-risk patients for whom a watch-and-wait strategy is acceptable,” he said.

The RIT technique is not new; it has been used to treat leukemia and lymphoma, but it has not been well studied in solid tumors. The patients in the current study underwent RIT after receiving an anti-CEA in the form of a bispecific monoclonal antibody (anti-diethylenetriamine pentaacetic acid indium BsMAb) that was followed 4 days later by iodine-131-labeled bivalent hapten.

In addition to demonstrating the success of RIT, the study identified calcitonin levels as a predictive factor of overall survival to help determine which patients are still at risk after thyroid cancer surgery.

The study compared the survival rates of 29 MTC patients who had radioimmunotherapy between 1996 and 2002 with those of 39 untreated MTC patients.

Patients in both the treated and untreated groups were divided into subgroups by calcitonin doubling time—a measure of serum calcitonin that can be predictive of cancer. Patients with calcitonin doubling times of less than 2 years were classified as high risk and patients with calcitonin doubling times of 2 years and higher were classified as low risk.

Overall median survival rates were significantly longer in the treated vs. the untreated patients within the subgroup of high-risk patients whose calcitonin doubling times were less than 2 years (110 months for treated patients vs. 61 months for untreated patients). The overall survival rates were not significantly different between treated and untreated patients when high- and low-risk patients were taken as a whole, which supports the predictive value of calcitonin doubling time.

A total of 10 of the 19 high-risk patients and all of the low-risk patients (9) who were treated with radioimmunotherapy had favorable biologic responses, defined as increase in calcitonin doubling time of more than 100% after treatment, compared with pretreatment. Complete outcome data were not available for an additional patient who developed myelodysplastic syndrome.

In addition, patients who had bone marrow disease responded well to RIT, which might be an indicator that the therapy reached the involved bone and bone marrow in these patients. Interestingly, patients with bone marrow disease had a significantly longer overall survival rate at 10 years, compared with patients without bone marrow involvement (83% vs. 14%).

In 34 patients for whom toxicity data were available, RIT was associated with mild liver toxicity (grade 1 or 2) in 5 patients and serious toxicity (grade 4) in 8 patients. The toxicity lasted for an average of 20 days. One patient developed myelodysplastic syndrome, but this patient had received two previous radioactive iodine treatments before enrolling in the current study, Dr. Bardet said.

PHOENIX — Radioimmunotherapy has the potential to prolong survival in patients with advanced medullary thyroid carcinoma, based on data from a small but promising study presented at the annual meeting of the American Thyroid Association.

Medullary thyroid carcinoma (MTC) differs from other solid tumors in that it progresses slowly when untreated, so even a slight treatment impact may have a large payoff in terms of months of life gained.

Dr. Stéphane Bardet, head of the nuclear medicine department at the Centre François Baclesse, in Caen, France, presented findings from a study published earlier this year in the April issue of the Journal of Clinical Oncology in which the use of pretargeted anticarcinoembryonic antigen (anti-CEA) radioimmunotherapy (RIT) successfully detected malignant lesions and resulted in a higher dose of radiation to tumor cells (J. Clin. Oncol. 2006;24:1705–11).

Radioactive iodine therapy is often used to destroy remaining thyroid tissue after thyroid cancer surgery. RIT includes an antibody, as well as the iodine, that works to target the cancerous tissue more effectively than iodine alone. “It's important to identify high-risk patients who need to be treated after surgery as early as possible, versus low-risk patients for whom a watch-and-wait strategy is acceptable,” he said.

The RIT technique is not new; it has been used to treat leukemia and lymphoma, but it has not been well studied in solid tumors. The patients in the current study underwent RIT after receiving an anti-CEA in the form of a bispecific monoclonal antibody (anti-diethylenetriamine pentaacetic acid indium BsMAb) that was followed 4 days later by iodine-131-labeled bivalent hapten.

In addition to demonstrating the success of RIT, the study identified calcitonin levels as a predictive factor of overall survival to help determine which patients are still at risk after thyroid cancer surgery.

The study compared the survival rates of 29 MTC patients who had radioimmunotherapy between 1996 and 2002 with those of 39 untreated MTC patients.

Patients in both the treated and untreated groups were divided into subgroups by calcitonin doubling time—a measure of serum calcitonin that can be predictive of cancer. Patients with calcitonin doubling times of less than 2 years were classified as high risk and patients with calcitonin doubling times of 2 years and higher were classified as low risk.

Overall median survival rates were significantly longer in the treated vs. the untreated patients within the subgroup of high-risk patients whose calcitonin doubling times were less than 2 years (110 months for treated patients vs. 61 months for untreated patients). The overall survival rates were not significantly different between treated and untreated patients when high- and low-risk patients were taken as a whole, which supports the predictive value of calcitonin doubling time.

A total of 10 of the 19 high-risk patients and all of the low-risk patients (9) who were treated with radioimmunotherapy had favorable biologic responses, defined as increase in calcitonin doubling time of more than 100% after treatment, compared with pretreatment. Complete outcome data were not available for an additional patient who developed myelodysplastic syndrome.

In addition, patients who had bone marrow disease responded well to RIT, which might be an indicator that the therapy reached the involved bone and bone marrow in these patients. Interestingly, patients with bone marrow disease had a significantly longer overall survival rate at 10 years, compared with patients without bone marrow involvement (83% vs. 14%).

In 34 patients for whom toxicity data were available, RIT was associated with mild liver toxicity (grade 1 or 2) in 5 patients and serious toxicity (grade 4) in 8 patients. The toxicity lasted for an average of 20 days. One patient developed myelodysplastic syndrome, but this patient had received two previous radioactive iodine treatments before enrolling in the current study, Dr. Bardet said.

PHOENIX — Radioimmunotherapy has the potential to prolong survival in patients with advanced medullary thyroid carcinoma, based on data from a small but promising study presented at the annual meeting of the American Thyroid Association.

Medullary thyroid carcinoma (MTC) differs from other solid tumors in that it progresses slowly when untreated, so even a slight treatment impact may have a large payoff in terms of months of life gained.

Dr. Stéphane Bardet, head of the nuclear medicine department at the Centre François Baclesse, in Caen, France, presented findings from a study published earlier this year in the April issue of the Journal of Clinical Oncology in which the use of pretargeted anticarcinoembryonic antigen (anti-CEA) radioimmunotherapy (RIT) successfully detected malignant lesions and resulted in a higher dose of radiation to tumor cells (J. Clin. Oncol. 2006;24:1705–11).

Radioactive iodine therapy is often used to destroy remaining thyroid tissue after thyroid cancer surgery. RIT includes an antibody, as well as the iodine, that works to target the cancerous tissue more effectively than iodine alone. “It's important to identify high-risk patients who need to be treated after surgery as early as possible, versus low-risk patients for whom a watch-and-wait strategy is acceptable,” he said.

The RIT technique is not new; it has been used to treat leukemia and lymphoma, but it has not been well studied in solid tumors. The patients in the current study underwent RIT after receiving an anti-CEA in the form of a bispecific monoclonal antibody (anti-diethylenetriamine pentaacetic acid indium BsMAb) that was followed 4 days later by iodine-131-labeled bivalent hapten.

In addition to demonstrating the success of RIT, the study identified calcitonin levels as a predictive factor of overall survival to help determine which patients are still at risk after thyroid cancer surgery.

The study compared the survival rates of 29 MTC patients who had radioimmunotherapy between 1996 and 2002 with those of 39 untreated MTC patients.

Patients in both the treated and untreated groups were divided into subgroups by calcitonin doubling time—a measure of serum calcitonin that can be predictive of cancer. Patients with calcitonin doubling times of less than 2 years were classified as high risk and patients with calcitonin doubling times of 2 years and higher were classified as low risk.

Overall median survival rates were significantly longer in the treated vs. the untreated patients within the subgroup of high-risk patients whose calcitonin doubling times were less than 2 years (110 months for treated patients vs. 61 months for untreated patients). The overall survival rates were not significantly different between treated and untreated patients when high- and low-risk patients were taken as a whole, which supports the predictive value of calcitonin doubling time.

A total of 10 of the 19 high-risk patients and all of the low-risk patients (9) who were treated with radioimmunotherapy had favorable biologic responses, defined as increase in calcitonin doubling time of more than 100% after treatment, compared with pretreatment. Complete outcome data were not available for an additional patient who developed myelodysplastic syndrome.

In addition, patients who had bone marrow disease responded well to RIT, which might be an indicator that the therapy reached the involved bone and bone marrow in these patients. Interestingly, patients with bone marrow disease had a significantly longer overall survival rate at 10 years, compared with patients without bone marrow involvement (83% vs. 14%).

In 34 patients for whom toxicity data were available, RIT was associated with mild liver toxicity (grade 1 or 2) in 5 patients and serious toxicity (grade 4) in 8 patients. The toxicity lasted for an average of 20 days. One patient developed myelodysplastic syndrome, but this patient had received two previous radioactive iodine treatments before enrolling in the current study, Dr. Bardet said.

Response to Sertraline Varies with Age

Children aged 6–11 years with major depressive disorder had a significantly faster first response to both sertraline and placebo, compared with adolescents aged 12–17 years, Dr. Craig L. Donnelly of Darmouth-Hitchcock Medical Center in Lebanon, N.H., and his colleagues report.

The study, funded by Pfizer Inc., is the first known to examine the differences in time to first response and time to first persistent response in children and adolescents with major depressive disorder (MDD).

The investigators looked at 226 youths with MDD. The 10-week double-blind, placebo-controlled trial was followed by a 24-week open-label trial of sertraline. All the patients who received sertraline started with a 25 mg/day dose for 3 days, followed by 50 mg/day through the end of 2 weeks. The dosage was then adjusted to a maximum of 200 mg/day based on the patient's clinical response and the occurrence of side effects (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1162–70).

The estimated median time to first response was 15 days for children and 22 days for adolescents who took sertraline, compared with 21 days for children and 23 days for adolescents who took a placebo.

In contrast to the time to first response, the time to first persistent response was significantly shorter among adolescents–but not among younger children–when compared with the placebo.

The estimated median time to first persistent response was 28 days for children and 32 days for adolescents who took sertraline, compared with 28 days for children and 32 days for adolescents who took a placebo. Patients in both age groups showed similar long-term improvements in the symptoms of MDD by the end of 34 weeks of treatment.

Somatic Symptoms, Childhood Anxiety

A majority of children with a DSM-IV anxiety disorder report at least one somatic symptom, according to data from 128 children and adolescents aged 6–17 years, wrote Golda S. Ginsburg, Ph.D., of Johns Hopkins University, Baltimore.

Previous studies have shown that somatic symptoms are common in children and adolescents with different types of anxiety, but somatic symptoms are listed in the DSM-IV only as part of the diagnosis of generalized anxiety disorder in children.

Dr. Ginsburg and her colleagues conducted a double-blind, placebo-controlled trial to assess the relationship among somatic symptoms and generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and social phobia (SOP), as well as the potential for treatment of somatic symptoms with fluvoxamine (Luvox).

Overall, 123 children (96%) reported at least one somatic symptom, with an average of six symptoms reported per child, according to the study. Children with GAD reported significantly more somatic symptoms than children without GAD, while children with and without SAD and SOP reported similar numbers of symptoms, compared with children without these diagnoses (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1179–87).

But the most common somatic symptoms in patients with any of the three diagnoses were restlessness (74%) and stomachaches (70%). The high prevalence supports the inclusion of these symptoms in the diagnostic criteria not only for GAD but also for SAD and SOP in children in the DSM-V, the researchers said.

Nicotine Use Not Linked to Psychosis

Dependence on nicotine is significantly associated with substance use disorders rather than psychotic disorders, a study of 342 adolescent psychiatric inpatients shows.

These results are in contrast to those on nicotine use and psychiatric conditions in previous studies, which have shown a link between excessive smoking and psychotic disorders. However, most of those studies have involved adult psychiatric inpatients.

To determine the association between nicotine dependence and psychiatric conditions in adolescents, Dr. Helina Hakko of Oulu (Finland) University Hospital and her colleagues evaluated nicotine use in 142 boys and 200 girls aged 12–17 years who were being treated for psychotic disorders (Addict. Behav. 2006;31:1873–80).

A total of 259 adolescents (76%) were smokers at the time of the study. Complete nicotine data were not available for 11 of the smokers. The researchers found a high level of nicotine dependence in 94 (38%) of the remaining 248 adolescents.

Increased levels of nicotine dependence were significantly associated with substance-related disorders and conduct/oppositional defiant disorders. In contrast to studies in adults, the adolescents diagnosed with psychotic disorders had significantly less nicotine dependence than did those without psychotic disorders.

The findings suggest a possible pattern of defiant behavior, including cigarette use and use of other substances, or an increased vulnerability to nicotine among adolescents who suffer from conduct disorders, the researchers said.

Response to Sertraline Varies with Age

Children aged 6–11 years with major depressive disorder had a significantly faster first response to both sertraline and placebo, compared with adolescents aged 12–17 years, Dr. Craig L. Donnelly of Darmouth-Hitchcock Medical Center in Lebanon, N.H., and his colleagues report.

The study, funded by Pfizer Inc., is the first known to examine the differences in time to first response and time to first persistent response in children and adolescents with major depressive disorder (MDD).

The investigators looked at 226 youths with MDD. The 10-week double-blind, placebo-controlled trial was followed by a 24-week open-label trial of sertraline. All the patients who received sertraline started with a 25 mg/day dose for 3 days, followed by 50 mg/day through the end of 2 weeks. The dosage was then adjusted to a maximum of 200 mg/day based on the patient's clinical response and the occurrence of side effects (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1162–70).

The estimated median time to first response was 15 days for children and 22 days for adolescents who took sertraline, compared with 21 days for children and 23 days for adolescents who took a placebo.

In contrast to the time to first response, the time to first persistent response was significantly shorter among adolescents–but not among younger children–when compared with the placebo.

The estimated median time to first persistent response was 28 days for children and 32 days for adolescents who took sertraline, compared with 28 days for children and 32 days for adolescents who took a placebo. Patients in both age groups showed similar long-term improvements in the symptoms of MDD by the end of 34 weeks of treatment.

Somatic Symptoms, Childhood Anxiety

A majority of children with a DSM-IV anxiety disorder report at least one somatic symptom, according to data from 128 children and adolescents aged 6–17 years, wrote Golda S. Ginsburg, Ph.D., of Johns Hopkins University, Baltimore.

Previous studies have shown that somatic symptoms are common in children and adolescents with different types of anxiety, but somatic symptoms are listed in the DSM-IV only as part of the diagnosis of generalized anxiety disorder in children.

Dr. Ginsburg and her colleagues conducted a double-blind, placebo-controlled trial to assess the relationship among somatic symptoms and generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and social phobia (SOP), as well as the potential for treatment of somatic symptoms with fluvoxamine (Luvox).

Overall, 123 children (96%) reported at least one somatic symptom, with an average of six symptoms reported per child, according to the study. Children with GAD reported significantly more somatic symptoms than children without GAD, while children with and without SAD and SOP reported similar numbers of symptoms, compared with children without these diagnoses (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1179–87).

But the most common somatic symptoms in patients with any of the three diagnoses were restlessness (74%) and stomachaches (70%). The high prevalence supports the inclusion of these symptoms in the diagnostic criteria not only for GAD but also for SAD and SOP in children in the DSM-V, the researchers said.

Nicotine Use Not Linked to Psychosis

Dependence on nicotine is significantly associated with substance use disorders rather than psychotic disorders, a study of 342 adolescent psychiatric inpatients shows.

These results are in contrast to those on nicotine use and psychiatric conditions in previous studies, which have shown a link between excessive smoking and psychotic disorders. However, most of those studies have involved adult psychiatric inpatients.

To determine the association between nicotine dependence and psychiatric conditions in adolescents, Dr. Helina Hakko of Oulu (Finland) University Hospital and her colleagues evaluated nicotine use in 142 boys and 200 girls aged 12–17 years who were being treated for psychotic disorders (Addict. Behav. 2006;31:1873–80).

A total of 259 adolescents (76%) were smokers at the time of the study. Complete nicotine data were not available for 11 of the smokers. The researchers found a high level of nicotine dependence in 94 (38%) of the remaining 248 adolescents.

Increased levels of nicotine dependence were significantly associated with substance-related disorders and conduct/oppositional defiant disorders. In contrast to studies in adults, the adolescents diagnosed with psychotic disorders had significantly less nicotine dependence than did those without psychotic disorders.

The findings suggest a possible pattern of defiant behavior, including cigarette use and use of other substances, or an increased vulnerability to nicotine among adolescents who suffer from conduct disorders, the researchers said.

Response to Sertraline Varies with Age

Children aged 6–11 years with major depressive disorder had a significantly faster first response to both sertraline and placebo, compared with adolescents aged 12–17 years, Dr. Craig L. Donnelly of Darmouth-Hitchcock Medical Center in Lebanon, N.H., and his colleagues report.

The study, funded by Pfizer Inc., is the first known to examine the differences in time to first response and time to first persistent response in children and adolescents with major depressive disorder (MDD).

The investigators looked at 226 youths with MDD. The 10-week double-blind, placebo-controlled trial was followed by a 24-week open-label trial of sertraline. All the patients who received sertraline started with a 25 mg/day dose for 3 days, followed by 50 mg/day through the end of 2 weeks. The dosage was then adjusted to a maximum of 200 mg/day based on the patient's clinical response and the occurrence of side effects (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1162–70).

The estimated median time to first response was 15 days for children and 22 days for adolescents who took sertraline, compared with 21 days for children and 23 days for adolescents who took a placebo.

In contrast to the time to first response, the time to first persistent response was significantly shorter among adolescents–but not among younger children–when compared with the placebo.

The estimated median time to first persistent response was 28 days for children and 32 days for adolescents who took sertraline, compared with 28 days for children and 32 days for adolescents who took a placebo. Patients in both age groups showed similar long-term improvements in the symptoms of MDD by the end of 34 weeks of treatment.

Somatic Symptoms, Childhood Anxiety

A majority of children with a DSM-IV anxiety disorder report at least one somatic symptom, according to data from 128 children and adolescents aged 6–17 years, wrote Golda S. Ginsburg, Ph.D., of Johns Hopkins University, Baltimore.

Previous studies have shown that somatic symptoms are common in children and adolescents with different types of anxiety, but somatic symptoms are listed in the DSM-IV only as part of the diagnosis of generalized anxiety disorder in children.

Dr. Ginsburg and her colleagues conducted a double-blind, placebo-controlled trial to assess the relationship among somatic symptoms and generalized anxiety disorder (GAD), separation anxiety disorder (SAD), and social phobia (SOP), as well as the potential for treatment of somatic symptoms with fluvoxamine (Luvox).

Overall, 123 children (96%) reported at least one somatic symptom, with an average of six symptoms reported per child, according to the study. Children with GAD reported significantly more somatic symptoms than children without GAD, while children with and without SAD and SOP reported similar numbers of symptoms, compared with children without these diagnoses (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1179–87).

But the most common somatic symptoms in patients with any of the three diagnoses were restlessness (74%) and stomachaches (70%). The high prevalence supports the inclusion of these symptoms in the diagnostic criteria not only for GAD but also for SAD and SOP in children in the DSM-V, the researchers said.

Nicotine Use Not Linked to Psychosis

Dependence on nicotine is significantly associated with substance use disorders rather than psychotic disorders, a study of 342 adolescent psychiatric inpatients shows.

These results are in contrast to those on nicotine use and psychiatric conditions in previous studies, which have shown a link between excessive smoking and psychotic disorders. However, most of those studies have involved adult psychiatric inpatients.

To determine the association between nicotine dependence and psychiatric conditions in adolescents, Dr. Helina Hakko of Oulu (Finland) University Hospital and her colleagues evaluated nicotine use in 142 boys and 200 girls aged 12–17 years who were being treated for psychotic disorders (Addict. Behav. 2006;31:1873–80).

A total of 259 adolescents (76%) were smokers at the time of the study. Complete nicotine data were not available for 11 of the smokers. The researchers found a high level of nicotine dependence in 94 (38%) of the remaining 248 adolescents.

Increased levels of nicotine dependence were significantly associated with substance-related disorders and conduct/oppositional defiant disorders. In contrast to studies in adults, the adolescents diagnosed with psychotic disorders had significantly less nicotine dependence than did those without psychotic disorders.

The findings suggest a possible pattern of defiant behavior, including cigarette use and use of other substances, or an increased vulnerability to nicotine among adolescents who suffer from conduct disorders, the researchers said.

WASHINGTON — The challenge of paying for vaccinations has become even greater now the human papillomavirus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, Dr. Rodewald said.

Consequently, an ACIP recommendation raises the possibility of disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children who have private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources?

“The programs are put in a tough spot,” Dr. Rodewald said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program.

Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage.

Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

WASHINGTON — The challenge of paying for vaccinations has become even greater now the human papillomavirus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, Dr. Rodewald said.

Consequently, an ACIP recommendation raises the possibility of disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children who have private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources?

“The programs are put in a tough spot,” Dr. Rodewald said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program.

Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage.

Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

WASHINGTON — The challenge of paying for vaccinations has become even greater now the human papillomavirus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, Dr. Rodewald said.

Consequently, an ACIP recommendation raises the possibility of disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children who have private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources?

“The programs are put in a tough spot,” Dr. Rodewald said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program.

Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage.

Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

WASHINGTON — Clinicians should be proactive in checking their HIV patients for herpes and syphilis because of the risk of coinfection, Dr. Connie Celum said at the Ryan White CARE Act meeting on HIV treatment.

“If you don't look for STDs in HIV patients, you won't find them,” said Dr. Celum of the University of Washington, Seattle.

Individuals with STDs are two to five times more likely than those without STDs to become infected with HIV if they are exposed through sexual contact, according to data from the Centers for Disease Control and Prevention.

Comorbid STDs often go undetected in HIV patients, but an HIV-infected person who is coinfected with an STD is more likely to transmit HIV than an HIV-infected person without a comorbid STD.

Genital herpes is the most common sexually transmitted infection among HIV-positive persons, Dr. Celum said. Previous studies have shown that the herpes virus (HSV-2) increases one's risk of acquiring HIV and increases HIV RNA levels in plasma and in the genital tract; the presence of herpes also makes a person more likely to transmit HIV.

Conversely, the presence of HIV can reactivate herpes that has been dormant. HIV also increases the frequency of HSV-2 shedding in persons with herpes and increases the risk of acquiring and transmitting the herpes virus. A recent study by Dr. Celum and her colleagues at the University of Washington found that 50 HIV-positive men with herpes were 2.7 times more likely to shed the herpes virus orally, compared with 59 HIV-negative men with herpes (J. Infect. Dis. 2006;194:420–7).

A key question is, if you suppress herpes, can you reduce the likelihood of HIV infection? Suppression of herpes may be a strategy that buys more time for researchers who continue to work on other HIV treatments and interventions, Dr. Celum said.

Data from a proof-of-concept study including 140 women coinfected with HIV and herpes showed that treating herpes with valacyclovir significantly reduced HIV levels in plasma and the genital tract. The results were presented at the Conference on Retroviruses and Opportunistic Infections earlier this year, but useful clinical data are still 1–2 years away, she said.

The majority of herpes patients shed the virus in the genital tract. Although highly active antiretroviral treatment (HAART) may reduce symptoms of herpes, it does not reduce subclinical herpes shedding. Even if suppressing herpes infections with HAART can suppress the viral load in HIV patients, it remains to be seen whether treating herpes also reduces the likelihood of HIV infection.

Clinicians should also be vigilant in evaluating their HIV patients for syphilis because the annual incidence of syphilis is rising, especially among men who have sex with men, Dr. Celum explained.

The reasons for the resurgence of syphilis remain unclear, but some epidemiologic data suggest that improved therapy for HIV and improved survival and well-being among HIV patients may be driving the increase in cases, particularly among men who have sex with men. Most clinicians have limited experience in diagnosing syphilis, and they may not know it when they see it. Syphilis is a great imitator; the appearance of rashes and other signs of secondary syphilis vary from person to person.

Syphilis rashes may be widespread or subtle. The rashes are not usually itchy or vesicular, but they may include papules, macules, pustules, or ring- or lens-shaped lesions. A syphilis rash appears on the palms and soles in 60% of cases, not 100% of cases, so look elsewhere on the body for signs of infection after checking the palms and soles, Dr. Celum said. These symptoms usually appear after the chancres of primary syphilis have resolved. Syphilis manifestations are especially easy to miss in HIV-positive patients on HAART because these patients often develop rashes that resemble syphilis as a side effect of the medication.

Consequently, Dr. Celum recommends maintaining a high level of suspicion for syphilis in HIV-positive patients because of the increased risk of HIV transmission. She suggests treating for syphilis in possible as well as definite cases.

The most up-to-date treatment guidelines for syphilis and other STDs are available on the Centers for Disease Control and Prevention Web site at www.cdc.gov/std

WASHINGTON — Clinicians should be proactive in checking their HIV patients for herpes and syphilis because of the risk of coinfection, Dr. Connie Celum said at the Ryan White CARE Act meeting on HIV treatment.

“If you don't look for STDs in HIV patients, you won't find them,” said Dr. Celum of the University of Washington, Seattle.

Individuals with STDs are two to five times more likely than those without STDs to become infected with HIV if they are exposed through sexual contact, according to data from the Centers for Disease Control and Prevention.

Comorbid STDs often go undetected in HIV patients, but an HIV-infected person who is coinfected with an STD is more likely to transmit HIV than an HIV-infected person without a comorbid STD.

Genital herpes is the most common sexually transmitted infection among HIV-positive persons, Dr. Celum said. Previous studies have shown that the herpes virus (HSV-2) increases one's risk of acquiring HIV and increases HIV RNA levels in plasma and in the genital tract; the presence of herpes also makes a person more likely to transmit HIV.

Conversely, the presence of HIV can reactivate herpes that has been dormant. HIV also increases the frequency of HSV-2 shedding in persons with herpes and increases the risk of acquiring and transmitting the herpes virus. A recent study by Dr. Celum and her colleagues at the University of Washington found that 50 HIV-positive men with herpes were 2.7 times more likely to shed the herpes virus orally, compared with 59 HIV-negative men with herpes (J. Infect. Dis. 2006;194:420–7).

A key question is, if you suppress herpes, can you reduce the likelihood of HIV infection? Suppression of herpes may be a strategy that buys more time for researchers who continue to work on other HIV treatments and interventions, Dr. Celum said.

Data from a proof-of-concept study including 140 women coinfected with HIV and herpes showed that treating herpes with valacyclovir significantly reduced HIV levels in plasma and the genital tract. The results were presented at the Conference on Retroviruses and Opportunistic Infections earlier this year, but useful clinical data are still 1–2 years away, she said.

The majority of herpes patients shed the virus in the genital tract. Although highly active antiretroviral treatment (HAART) may reduce symptoms of herpes, it does not reduce subclinical herpes shedding. Even if suppressing herpes infections with HAART can suppress the viral load in HIV patients, it remains to be seen whether treating herpes also reduces the likelihood of HIV infection.

Clinicians should also be vigilant in evaluating their HIV patients for syphilis because the annual incidence of syphilis is rising, especially among men who have sex with men, Dr. Celum explained.

The reasons for the resurgence of syphilis remain unclear, but some epidemiologic data suggest that improved therapy for HIV and improved survival and well-being among HIV patients may be driving the increase in cases, particularly among men who have sex with men. Most clinicians have limited experience in diagnosing syphilis, and they may not know it when they see it. Syphilis is a great imitator; the appearance of rashes and other signs of secondary syphilis vary from person to person.

Syphilis rashes may be widespread or subtle. The rashes are not usually itchy or vesicular, but they may include papules, macules, pustules, or ring- or lens-shaped lesions. A syphilis rash appears on the palms and soles in 60% of cases, not 100% of cases, so look elsewhere on the body for signs of infection after checking the palms and soles, Dr. Celum said. These symptoms usually appear after the chancres of primary syphilis have resolved. Syphilis manifestations are especially easy to miss in HIV-positive patients on HAART because these patients often develop rashes that resemble syphilis as a side effect of the medication.

Consequently, Dr. Celum recommends maintaining a high level of suspicion for syphilis in HIV-positive patients because of the increased risk of HIV transmission. She suggests treating for syphilis in possible as well as definite cases.

The most up-to-date treatment guidelines for syphilis and other STDs are available on the Centers for Disease Control and Prevention Web site at www.cdc.gov/std

WASHINGTON — Clinicians should be proactive in checking their HIV patients for herpes and syphilis because of the risk of coinfection, Dr. Connie Celum said at the Ryan White CARE Act meeting on HIV treatment.

“If you don't look for STDs in HIV patients, you won't find them,” said Dr. Celum of the University of Washington, Seattle.

Individuals with STDs are two to five times more likely than those without STDs to become infected with HIV if they are exposed through sexual contact, according to data from the Centers for Disease Control and Prevention.

Comorbid STDs often go undetected in HIV patients, but an HIV-infected person who is coinfected with an STD is more likely to transmit HIV than an HIV-infected person without a comorbid STD.

Genital herpes is the most common sexually transmitted infection among HIV-positive persons, Dr. Celum said. Previous studies have shown that the herpes virus (HSV-2) increases one's risk of acquiring HIV and increases HIV RNA levels in plasma and in the genital tract; the presence of herpes also makes a person more likely to transmit HIV.

Conversely, the presence of HIV can reactivate herpes that has been dormant. HIV also increases the frequency of HSV-2 shedding in persons with herpes and increases the risk of acquiring and transmitting the herpes virus. A recent study by Dr. Celum and her colleagues at the University of Washington found that 50 HIV-positive men with herpes were 2.7 times more likely to shed the herpes virus orally, compared with 59 HIV-negative men with herpes (J. Infect. Dis. 2006;194:420–7).

A key question is, if you suppress herpes, can you reduce the likelihood of HIV infection? Suppression of herpes may be a strategy that buys more time for researchers who continue to work on other HIV treatments and interventions, Dr. Celum said.

Data from a proof-of-concept study including 140 women coinfected with HIV and herpes showed that treating herpes with valacyclovir significantly reduced HIV levels in plasma and the genital tract. The results were presented at the Conference on Retroviruses and Opportunistic Infections earlier this year, but useful clinical data are still 1–2 years away, she said.

The majority of herpes patients shed the virus in the genital tract. Although highly active antiretroviral treatment (HAART) may reduce symptoms of herpes, it does not reduce subclinical herpes shedding. Even if suppressing herpes infections with HAART can suppress the viral load in HIV patients, it remains to be seen whether treating herpes also reduces the likelihood of HIV infection.

Clinicians should also be vigilant in evaluating their HIV patients for syphilis because the annual incidence of syphilis is rising, especially among men who have sex with men, Dr. Celum explained.

The reasons for the resurgence of syphilis remain unclear, but some epidemiologic data suggest that improved therapy for HIV and improved survival and well-being among HIV patients may be driving the increase in cases, particularly among men who have sex with men. Most clinicians have limited experience in diagnosing syphilis, and they may not know it when they see it. Syphilis is a great imitator; the appearance of rashes and other signs of secondary syphilis vary from person to person.

Syphilis rashes may be widespread or subtle. The rashes are not usually itchy or vesicular, but they may include papules, macules, pustules, or ring- or lens-shaped lesions. A syphilis rash appears on the palms and soles in 60% of cases, not 100% of cases, so look elsewhere on the body for signs of infection after checking the palms and soles, Dr. Celum said. These symptoms usually appear after the chancres of primary syphilis have resolved. Syphilis manifestations are especially easy to miss in HIV-positive patients on HAART because these patients often develop rashes that resemble syphilis as a side effect of the medication.

Consequently, Dr. Celum recommends maintaining a high level of suspicion for syphilis in HIV-positive patients because of the increased risk of HIV transmission. She suggests treating for syphilis in possible as well as definite cases.

The most up-to-date treatment guidelines for syphilis and other STDs are available on the Centers for Disease Control and Prevention Web site at www.cdc.gov/std

WASHINGTON — Atraumatic knee pain, especially on the outside of the knee, is a common complaint in primary care offices, and although its mechanisms are poorly understood, the pain is real, even in those lacking clinical symptoms such as redness or swelling.

Often, atraumatic knee pain is related to the cartilage behind the kneecap, Dr. Scott Flinn said at the annual meeting of the American Academy of Family Physicians.

“The retropatellar cartilage behind the knee is the thickest in the body—5 mm—and when the patella is extended, the cartilage causes pressure across the knee,” said Dr. Flinn, a family physician, Specialty Leader for Sports Medicine to the Surgeon General, and Force Surgeon for Commander Naval Surface Forces in San Diego, Calif.

Dr. Flinn presented diagnostic pearls, treatment strategies, and rehabilitation tips for getting patients with the following common causes of anterior atraumatic knee pain back to strength without surgery:

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is also known as runner's knee, chondromalacia patella, and patellofemoral arthralgia. Evidence suggests that there is a 20% prevalence of PFPS among individuals aged 12–20 years, and that this type of knee pain accounts for up to 30% of visits in some sports injury clinics.

With any type of atraumatic knee pain, Dr. Flinn said to be sure to ask patients about a history of trauma; feelings that the knee is catching, popping, locking, or giving way; and a history of swelling in or around the knee joint.

Other symptoms include patient reports of anterior knee pain while sitting for a long time (known as the “theater sign”); pain when walking down stairs, which is more common than pain walking up stairs; and pain when squatting, running, or jumping.

On physical examination, check for the quadriceps angle, or Q-angle, which is the angle created between a line drawn from the center of the anterior superior iliac spine on the pelvis to the center of the patella and a second line from the center of the patella to the middle of the tibial tubercle.

The greater the Q-angle the more likely a patient is to have PFPS, according to some studies. Patients who overpronate are more likely to have PFPS than are those whose stride is even. On palpation, clinicians may feel a tight lateral retinaculum. There may be a trace effusion, and patients with PFPS do not usually complain of instability or joint tenderness.

Rehab for PFPS includes improving flexibility in the hamstrings, iliotibial band, and lateral retinaculum. In particular, tightness in the lateral retinaculum (one of the fibrous bands that hold the patella in alignment) could contribute to the pain by causing the patella to ride laterally, which may contribute to the retropatellar pain of PFPS.

Many atraumatic injuries of the knee are caused by incorrect training or poor biomechanics, or a combination of the two. Consequently, the best treatment for PFPS includes physical therapy, with a focus on strengthening exercises for the outside of the quadriceps muscle (with an attempted focus on the vastus medialis oblique). Also, consider foot orthotics for patients who need to correct excessive pronation and imbalance.

Patellar Tendinitis

Patellar tendinitis is a misnomer because the condition is actually more of a tendinosis than tendinitis, Dr. Flinn said. Despite an initial inflammation, histology tends to show few inflammatory cells. Patients with “jumper's knee” usually hurt themselves by overusing the knee in an activity such as basketball or volleyball.

Patients present with almost no swelling, but they report anterior knee pain that worsens with activities such as running, jumping, using stairs, and squatting. Patellar tendinitis can occur in conjunction with PFPS, but the patient with patellar tendinitis alone usually does not experience the fullness in the knee that can accompany PFPS, nor do these patients tend to report feelings of locking, catching, or giving way in the knee. Foot orthotics or new shoes may correct overpronation.

Some patients with jumper's knee will find pain relief by using a patellar tendon strap, such as the Chopat strap—a rubber strap designed to change the forces across the patellar tendon and relieve the pain—which is available from most sporting goods stores, catalogs, and Web sites. “The patellar tendon strap tricks the body into thinking that forces are distributed differently around the knee,” Dr. Flinn explained.

Treatment and rehab strategies include anti-inflammatories; stretches for the quadriceps, hamstrings, and calf muscles (gastrocnemius and soleus); and exercises for the adductor muscles of the hip. Patients can usually ride a bike to help maintain fitness during recovery.

Prepatellar Bursitis

Also known as housemaid's knee, prepatellar bursitis is usually caused by repeated microtrauma associated with kneeling, but it can in rare circumstances be caused by an infection. Ask patients who present with atraumatic anterior knee pain accompanied by swelling and redness whether they spend much time scrubbing floors, gardening, laying carpet, or performing other activities that involve excessive kneeling or wearing hard knee pads.

A patient with an infected prepatellar bursa may present with fever, chills, and sweatiness. On physical exam, the area will be warm and tender to the touch, but that isn't enough to confirm or rule out sepsis. Get a cell count and gram stain to rule out infection. White blood cell counts are usually greater than 10,000 cells/mcL in septic patients but less than 1,000 cells/mcL in nonseptic patients.

As for treatment, Dr. Flinn recommends treating for gram-positive Staphylococcus aureus, which is the cause of 80% of these infections. Methicillin-resistant S. aureus (MRSA), Mycobacterium tuberculosis, and M. marinum are rare causes. Treatment should be based on cultures, whenever possible.

Prescribe ice packs and NSAIDs for nonseptic patients, and recommend a knee pad for protection in nonacute cases. Rehab for nonseptic patients is similar to strategies for other atraumatic anterior knee injuries and is based on the PRICEMM principles (see box). Focus on stretching and strengthening the quadriceps, hamstrings, and iliotibial band, and recommend the use of a cushioned knee pad, perhaps with a hard exterior shell, when the patient resumes activity.

A Twist on RICE For Management

In all cases of atraumatic knee pain, remember the principles of PRICEMM (an extension of the old standby RICE):

▸ Protect the injury from additional harm (with bracing, for example)

▸ Relative rest (maintain cardiovascular and strength training activities in other ways)

▸ Ice

▸ Compression

▸ Elevation

▸ Medications (NSAIDs for pain)

▸ Modalities for rehab (stretching, physical therapy)

WASHINGTON — Atraumatic knee pain, especially on the outside of the knee, is a common complaint in primary care offices, and although its mechanisms are poorly understood, the pain is real, even in those lacking clinical symptoms such as redness or swelling.

Often, atraumatic knee pain is related to the cartilage behind the kneecap, Dr. Scott Flinn said at the annual meeting of the American Academy of Family Physicians.

“The retropatellar cartilage behind the knee is the thickest in the body—5 mm—and when the patella is extended, the cartilage causes pressure across the knee,” said Dr. Flinn, a family physician, Specialty Leader for Sports Medicine to the Surgeon General, and Force Surgeon for Commander Naval Surface Forces in San Diego, Calif.

Dr. Flinn presented diagnostic pearls, treatment strategies, and rehabilitation tips for getting patients with the following common causes of anterior atraumatic knee pain back to strength without surgery:

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is also known as runner's knee, chondromalacia patella, and patellofemoral arthralgia. Evidence suggests that there is a 20% prevalence of PFPS among individuals aged 12–20 years, and that this type of knee pain accounts for up to 30% of visits in some sports injury clinics.

With any type of atraumatic knee pain, Dr. Flinn said to be sure to ask patients about a history of trauma; feelings that the knee is catching, popping, locking, or giving way; and a history of swelling in or around the knee joint.

Other symptoms include patient reports of anterior knee pain while sitting for a long time (known as the “theater sign”); pain when walking down stairs, which is more common than pain walking up stairs; and pain when squatting, running, or jumping.

On physical examination, check for the quadriceps angle, or Q-angle, which is the angle created between a line drawn from the center of the anterior superior iliac spine on the pelvis to the center of the patella and a second line from the center of the patella to the middle of the tibial tubercle.

The greater the Q-angle the more likely a patient is to have PFPS, according to some studies. Patients who overpronate are more likely to have PFPS than are those whose stride is even. On palpation, clinicians may feel a tight lateral retinaculum. There may be a trace effusion, and patients with PFPS do not usually complain of instability or joint tenderness.

Rehab for PFPS includes improving flexibility in the hamstrings, iliotibial band, and lateral retinaculum. In particular, tightness in the lateral retinaculum (one of the fibrous bands that hold the patella in alignment) could contribute to the pain by causing the patella to ride laterally, which may contribute to the retropatellar pain of PFPS.

Many atraumatic injuries of the knee are caused by incorrect training or poor biomechanics, or a combination of the two. Consequently, the best treatment for PFPS includes physical therapy, with a focus on strengthening exercises for the outside of the quadriceps muscle (with an attempted focus on the vastus medialis oblique). Also, consider foot orthotics for patients who need to correct excessive pronation and imbalance.

Patellar Tendinitis

Patellar tendinitis is a misnomer because the condition is actually more of a tendinosis than tendinitis, Dr. Flinn said. Despite an initial inflammation, histology tends to show few inflammatory cells. Patients with “jumper's knee” usually hurt themselves by overusing the knee in an activity such as basketball or volleyball.

Patients present with almost no swelling, but they report anterior knee pain that worsens with activities such as running, jumping, using stairs, and squatting. Patellar tendinitis can occur in conjunction with PFPS, but the patient with patellar tendinitis alone usually does not experience the fullness in the knee that can accompany PFPS, nor do these patients tend to report feelings of locking, catching, or giving way in the knee. Foot orthotics or new shoes may correct overpronation.

Some patients with jumper's knee will find pain relief by using a patellar tendon strap, such as the Chopat strap—a rubber strap designed to change the forces across the patellar tendon and relieve the pain—which is available from most sporting goods stores, catalogs, and Web sites. “The patellar tendon strap tricks the body into thinking that forces are distributed differently around the knee,” Dr. Flinn explained.

Treatment and rehab strategies include anti-inflammatories; stretches for the quadriceps, hamstrings, and calf muscles (gastrocnemius and soleus); and exercises for the adductor muscles of the hip. Patients can usually ride a bike to help maintain fitness during recovery.

Prepatellar Bursitis

Also known as housemaid's knee, prepatellar bursitis is usually caused by repeated microtrauma associated with kneeling, but it can in rare circumstances be caused by an infection. Ask patients who present with atraumatic anterior knee pain accompanied by swelling and redness whether they spend much time scrubbing floors, gardening, laying carpet, or performing other activities that involve excessive kneeling or wearing hard knee pads.

A patient with an infected prepatellar bursa may present with fever, chills, and sweatiness. On physical exam, the area will be warm and tender to the touch, but that isn't enough to confirm or rule out sepsis. Get a cell count and gram stain to rule out infection. White blood cell counts are usually greater than 10,000 cells/mcL in septic patients but less than 1,000 cells/mcL in nonseptic patients.

As for treatment, Dr. Flinn recommends treating for gram-positive Staphylococcus aureus, which is the cause of 80% of these infections. Methicillin-resistant S. aureus (MRSA), Mycobacterium tuberculosis, and M. marinum are rare causes. Treatment should be based on cultures, whenever possible.

Prescribe ice packs and NSAIDs for nonseptic patients, and recommend a knee pad for protection in nonacute cases. Rehab for nonseptic patients is similar to strategies for other atraumatic anterior knee injuries and is based on the PRICEMM principles (see box). Focus on stretching and strengthening the quadriceps, hamstrings, and iliotibial band, and recommend the use of a cushioned knee pad, perhaps with a hard exterior shell, when the patient resumes activity.

A Twist on RICE For Management

In all cases of atraumatic knee pain, remember the principles of PRICEMM (an extension of the old standby RICE):

▸ Protect the injury from additional harm (with bracing, for example)

▸ Relative rest (maintain cardiovascular and strength training activities in other ways)

▸ Ice

▸ Compression

▸ Elevation

▸ Medications (NSAIDs for pain)

▸ Modalities for rehab (stretching, physical therapy)

WASHINGTON — Atraumatic knee pain, especially on the outside of the knee, is a common complaint in primary care offices, and although its mechanisms are poorly understood, the pain is real, even in those lacking clinical symptoms such as redness or swelling.

Often, atraumatic knee pain is related to the cartilage behind the kneecap, Dr. Scott Flinn said at the annual meeting of the American Academy of Family Physicians.

“The retropatellar cartilage behind the knee is the thickest in the body—5 mm—and when the patella is extended, the cartilage causes pressure across the knee,” said Dr. Flinn, a family physician, Specialty Leader for Sports Medicine to the Surgeon General, and Force Surgeon for Commander Naval Surface Forces in San Diego, Calif.

Dr. Flinn presented diagnostic pearls, treatment strategies, and rehabilitation tips for getting patients with the following common causes of anterior atraumatic knee pain back to strength without surgery:

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is also known as runner's knee, chondromalacia patella, and patellofemoral arthralgia. Evidence suggests that there is a 20% prevalence of PFPS among individuals aged 12–20 years, and that this type of knee pain accounts for up to 30% of visits in some sports injury clinics.

With any type of atraumatic knee pain, Dr. Flinn said to be sure to ask patients about a history of trauma; feelings that the knee is catching, popping, locking, or giving way; and a history of swelling in or around the knee joint.

Other symptoms include patient reports of anterior knee pain while sitting for a long time (known as the “theater sign”); pain when walking down stairs, which is more common than pain walking up stairs; and pain when squatting, running, or jumping.

On physical examination, check for the quadriceps angle, or Q-angle, which is the angle created between a line drawn from the center of the anterior superior iliac spine on the pelvis to the center of the patella and a second line from the center of the patella to the middle of the tibial tubercle.

The greater the Q-angle the more likely a patient is to have PFPS, according to some studies. Patients who overpronate are more likely to have PFPS than are those whose stride is even. On palpation, clinicians may feel a tight lateral retinaculum. There may be a trace effusion, and patients with PFPS do not usually complain of instability or joint tenderness.

Rehab for PFPS includes improving flexibility in the hamstrings, iliotibial band, and lateral retinaculum. In particular, tightness in the lateral retinaculum (one of the fibrous bands that hold the patella in alignment) could contribute to the pain by causing the patella to ride laterally, which may contribute to the retropatellar pain of PFPS.

Many atraumatic injuries of the knee are caused by incorrect training or poor biomechanics, or a combination of the two. Consequently, the best treatment for PFPS includes physical therapy, with a focus on strengthening exercises for the outside of the quadriceps muscle (with an attempted focus on the vastus medialis oblique). Also, consider foot orthotics for patients who need to correct excessive pronation and imbalance.

Patellar Tendinitis

Patellar tendinitis is a misnomer because the condition is actually more of a tendinosis than tendinitis, Dr. Flinn said. Despite an initial inflammation, histology tends to show few inflammatory cells. Patients with “jumper's knee” usually hurt themselves by overusing the knee in an activity such as basketball or volleyball.

Patients present with almost no swelling, but they report anterior knee pain that worsens with activities such as running, jumping, using stairs, and squatting. Patellar tendinitis can occur in conjunction with PFPS, but the patient with patellar tendinitis alone usually does not experience the fullness in the knee that can accompany PFPS, nor do these patients tend to report feelings of locking, catching, or giving way in the knee. Foot orthotics or new shoes may correct overpronation.

Some patients with jumper's knee will find pain relief by using a patellar tendon strap, such as the Chopat strap—a rubber strap designed to change the forces across the patellar tendon and relieve the pain—which is available from most sporting goods stores, catalogs, and Web sites. “The patellar tendon strap tricks the body into thinking that forces are distributed differently around the knee,” Dr. Flinn explained.

Treatment and rehab strategies include anti-inflammatories; stretches for the quadriceps, hamstrings, and calf muscles (gastrocnemius and soleus); and exercises for the adductor muscles of the hip. Patients can usually ride a bike to help maintain fitness during recovery.

Prepatellar Bursitis

Also known as housemaid's knee, prepatellar bursitis is usually caused by repeated microtrauma associated with kneeling, but it can in rare circumstances be caused by an infection. Ask patients who present with atraumatic anterior knee pain accompanied by swelling and redness whether they spend much time scrubbing floors, gardening, laying carpet, or performing other activities that involve excessive kneeling or wearing hard knee pads.

A patient with an infected prepatellar bursa may present with fever, chills, and sweatiness. On physical exam, the area will be warm and tender to the touch, but that isn't enough to confirm or rule out sepsis. Get a cell count and gram stain to rule out infection. White blood cell counts are usually greater than 10,000 cells/mcL in septic patients but less than 1,000 cells/mcL in nonseptic patients.

As for treatment, Dr. Flinn recommends treating for gram-positive Staphylococcus aureus, which is the cause of 80% of these infections. Methicillin-resistant S. aureus (MRSA), Mycobacterium tuberculosis, and M. marinum are rare causes. Treatment should be based on cultures, whenever possible.

Prescribe ice packs and NSAIDs for nonseptic patients, and recommend a knee pad for protection in nonacute cases. Rehab for nonseptic patients is similar to strategies for other atraumatic anterior knee injuries and is based on the PRICEMM principles (see box). Focus on stretching and strengthening the quadriceps, hamstrings, and iliotibial band, and recommend the use of a cushioned knee pad, perhaps with a hard exterior shell, when the patient resumes activity.

A Twist on RICE For Management

In all cases of atraumatic knee pain, remember the principles of PRICEMM (an extension of the old standby RICE):

▸ Protect the injury from additional harm (with bracing, for example)

▸ Relative rest (maintain cardiovascular and strength training activities in other ways)

▸ Ice

▸ Compression

▸ Elevation

▸ Medications (NSAIDs for pain)

▸ Modalities for rehab (stretching, physical therapy)

CHARLESTON, W.VA. — Ischemic heart disease patients with comorbid diabetes start cardiac rehabilitation programs at a disadvantage: They have less lung power than nondiabetic heart disease patients do, according to a poster presented at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation.

To identify possible deficits in oxygen consumption among diabetic heart disease patients, Bradly Chapman, an exercise physiologist at the University of Toledo, Ohio, and his colleagues measured peak oxygen consumption in 76 diabetic and 114 nondiabetic adults at the start of a standard cardiac rehabilitation program.

The researchers assessed the patients using a motorized treadmill and determined peak oxygen consumption (VO₂) by using the highest recorded measurement based on an average of every 5–7 breaths. The diabetic and nondiabetic groups were matched for age and weight, and the heart disease diagnoses were not significantly different between the two groups.

The mean peak VO₂ of the diabetic patients was found to be 17.2 mL/kg per minute, compared with 20.2 mL/kg per minute for the nondiabetic patients, a significant difference.

Previous studies have shown that exercise training should be encouraged in cardiac patients with diabetes because it not only improves aerobic capacity but also promotes better diabetes management, the researchers wrote. The findings that the diabetic patients had a lower oxygen capacity suggest that exercise training could have an even greater clinical benefit for diabetic coronary patients than it does for nondiabetic patients, they said.

The researchers did not reassess the patients at the end of the rehabilitation program. But the study supports previous findings that peak oxygen consumption tends to be lower in diabetic heart disease patients than in nondiabetic patients.

CHARLESTON, W.VA. — Ischemic heart disease patients with comorbid diabetes start cardiac rehabilitation programs at a disadvantage: They have less lung power than nondiabetic heart disease patients do, according to a poster presented at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation.

To identify possible deficits in oxygen consumption among diabetic heart disease patients, Bradly Chapman, an exercise physiologist at the University of Toledo, Ohio, and his colleagues measured peak oxygen consumption in 76 diabetic and 114 nondiabetic adults at the start of a standard cardiac rehabilitation program.

The researchers assessed the patients using a motorized treadmill and determined peak oxygen consumption (VO₂) by using the highest recorded measurement based on an average of every 5–7 breaths. The diabetic and nondiabetic groups were matched for age and weight, and the heart disease diagnoses were not significantly different between the two groups.

The mean peak VO₂ of the diabetic patients was found to be 17.2 mL/kg per minute, compared with 20.2 mL/kg per minute for the nondiabetic patients, a significant difference.

Previous studies have shown that exercise training should be encouraged in cardiac patients with diabetes because it not only improves aerobic capacity but also promotes better diabetes management, the researchers wrote. The findings that the diabetic patients had a lower oxygen capacity suggest that exercise training could have an even greater clinical benefit for diabetic coronary patients than it does for nondiabetic patients, they said.

The researchers did not reassess the patients at the end of the rehabilitation program. But the study supports previous findings that peak oxygen consumption tends to be lower in diabetic heart disease patients than in nondiabetic patients.

CHARLESTON, W.VA. — Ischemic heart disease patients with comorbid diabetes start cardiac rehabilitation programs at a disadvantage: They have less lung power than nondiabetic heart disease patients do, according to a poster presented at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation.

To identify possible deficits in oxygen consumption among diabetic heart disease patients, Bradly Chapman, an exercise physiologist at the University of Toledo, Ohio, and his colleagues measured peak oxygen consumption in 76 diabetic and 114 nondiabetic adults at the start of a standard cardiac rehabilitation program.

The researchers assessed the patients using a motorized treadmill and determined peak oxygen consumption (VO₂) by using the highest recorded measurement based on an average of every 5–7 breaths. The diabetic and nondiabetic groups were matched for age and weight, and the heart disease diagnoses were not significantly different between the two groups.

The mean peak VO₂ of the diabetic patients was found to be 17.2 mL/kg per minute, compared with 20.2 mL/kg per minute for the nondiabetic patients, a significant difference.

Previous studies have shown that exercise training should be encouraged in cardiac patients with diabetes because it not only improves aerobic capacity but also promotes better diabetes management, the researchers wrote. The findings that the diabetic patients had a lower oxygen capacity suggest that exercise training could have an even greater clinical benefit for diabetic coronary patients than it does for nondiabetic patients, they said.

The researchers did not reassess the patients at the end of the rehabilitation program. But the study supports previous findings that peak oxygen consumption tends to be lower in diabetic heart disease patients than in nondiabetic patients.

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.