Jane Salodof MacNeil

VERSAILLES, FRANCE — A small retrospective study found the monoclonal antibody rituximab benefited 7 of 11 French children with severe systemic lupus erythematosus.

The wide variation in regimens used at different French centers does not allow any firm conclusions to be drawn, investigator Marjolaine Willems, M.D., said in a presentation at the 12th European Pediatric Rheumatology Congress.

Dr. Willems of Hôpital de Bicêtre, Kremlin-Bicêtre, France, called for prospective trials to assess long-term safety and efficacy of rituximab in comparison with cyclophosphamide. “It needs to be investigated in future prospective studies,” she said.

The patients, all girls, were nearly 14 years old on average when they started rituximab treatment. Eight patients had class IV or V nephritis, and two had autoimmune cytopenia. One girl had hypoprothrombinemia, class II nephritis, and pulmonary hypertension.

Nine patients had a prior history of nephritis, and all were on immunosuppressive regimens previously. Two were also treated with cyclophosphamide. The average follow-up was 13 months.

Dr. Willems and her coauthors reported that 9 out of 12 courses of rituximab resulted in complete or partial remissions. Treatment failed in two patients, and was not tolerated in another.

Six of the eight patients with renal involvement achieved complete or partial remissions. Antiphosphoid antibodies became negative in three of four patients. Normalization of CD3 and/or CD4 was reported in four of eight patients.

Five children had mild side effects, such as rash, mild neutropenia, and benign infections. Five others had severe hematologic toxicity, including septicemia, thrombopenia, neutropenia, and lymphopenia.

B-cell depletion appeared to parallel clinical remissions but was not consistent in all patients, according to Dr. Willems. She advocated monitoring B-cell depletion in children treated with rituximab.

Issues that still need to be addressed in pediatric randomized trials include the optimal regimen of rituximab, cotreatment with cyclophosphamide, maintenance of immunosuppression, and long-term effects.

“We've got so much heterogeneity in the rituximab regimens and confounding factors that cannot lead us to a good conclusion,” she said in an interview.

The most that can be said is that “some patients who did not respond to cyclophosphamide alone had a good response with rituximab,” and some patients who had been taking maintenance therapies without rituximab had a relapse and then did well after adding rituximab to their maintenance therapy.

VERSAILLES, FRANCE — A small retrospective study found the monoclonal antibody rituximab benefited 7 of 11 French children with severe systemic lupus erythematosus.

The wide variation in regimens used at different French centers does not allow any firm conclusions to be drawn, investigator Marjolaine Willems, M.D., said in a presentation at the 12th European Pediatric Rheumatology Congress.

Dr. Willems of Hôpital de Bicêtre, Kremlin-Bicêtre, France, called for prospective trials to assess long-term safety and efficacy of rituximab in comparison with cyclophosphamide. “It needs to be investigated in future prospective studies,” she said.

The patients, all girls, were nearly 14 years old on average when they started rituximab treatment. Eight patients had class IV or V nephritis, and two had autoimmune cytopenia. One girl had hypoprothrombinemia, class II nephritis, and pulmonary hypertension.

Nine patients had a prior history of nephritis, and all were on immunosuppressive regimens previously. Two were also treated with cyclophosphamide. The average follow-up was 13 months.

Dr. Willems and her coauthors reported that 9 out of 12 courses of rituximab resulted in complete or partial remissions. Treatment failed in two patients, and was not tolerated in another.

Six of the eight patients with renal involvement achieved complete or partial remissions. Antiphosphoid antibodies became negative in three of four patients. Normalization of CD3 and/or CD4 was reported in four of eight patients.

Five children had mild side effects, such as rash, mild neutropenia, and benign infections. Five others had severe hematologic toxicity, including septicemia, thrombopenia, neutropenia, and lymphopenia.

B-cell depletion appeared to parallel clinical remissions but was not consistent in all patients, according to Dr. Willems. She advocated monitoring B-cell depletion in children treated with rituximab.

Issues that still need to be addressed in pediatric randomized trials include the optimal regimen of rituximab, cotreatment with cyclophosphamide, maintenance of immunosuppression, and long-term effects.

“We've got so much heterogeneity in the rituximab regimens and confounding factors that cannot lead us to a good conclusion,” she said in an interview.

The most that can be said is that “some patients who did not respond to cyclophosphamide alone had a good response with rituximab,” and some patients who had been taking maintenance therapies without rituximab had a relapse and then did well after adding rituximab to their maintenance therapy.

VERSAILLES, FRANCE — A small retrospective study found the monoclonal antibody rituximab benefited 7 of 11 French children with severe systemic lupus erythematosus.

The wide variation in regimens used at different French centers does not allow any firm conclusions to be drawn, investigator Marjolaine Willems, M.D., said in a presentation at the 12th European Pediatric Rheumatology Congress.

Dr. Willems of Hôpital de Bicêtre, Kremlin-Bicêtre, France, called for prospective trials to assess long-term safety and efficacy of rituximab in comparison with cyclophosphamide. “It needs to be investigated in future prospective studies,” she said.

The patients, all girls, were nearly 14 years old on average when they started rituximab treatment. Eight patients had class IV or V nephritis, and two had autoimmune cytopenia. One girl had hypoprothrombinemia, class II nephritis, and pulmonary hypertension.

Nine patients had a prior history of nephritis, and all were on immunosuppressive regimens previously. Two were also treated with cyclophosphamide. The average follow-up was 13 months.

Dr. Willems and her coauthors reported that 9 out of 12 courses of rituximab resulted in complete or partial remissions. Treatment failed in two patients, and was not tolerated in another.

Six of the eight patients with renal involvement achieved complete or partial remissions. Antiphosphoid antibodies became negative in three of four patients. Normalization of CD3 and/or CD4 was reported in four of eight patients.

Five children had mild side effects, such as rash, mild neutropenia, and benign infections. Five others had severe hematologic toxicity, including septicemia, thrombopenia, neutropenia, and lymphopenia.

B-cell depletion appeared to parallel clinical remissions but was not consistent in all patients, according to Dr. Willems. She advocated monitoring B-cell depletion in children treated with rituximab.

Issues that still need to be addressed in pediatric randomized trials include the optimal regimen of rituximab, cotreatment with cyclophosphamide, maintenance of immunosuppression, and long-term effects.

“We've got so much heterogeneity in the rituximab regimens and confounding factors that cannot lead us to a good conclusion,” she said in an interview.

The most that can be said is that “some patients who did not respond to cyclophosphamide alone had a good response with rituximab,” and some patients who had been taking maintenance therapies without rituximab had a relapse and then did well after adding rituximab to their maintenance therapy.

VERSAILLES, FRANCE — A multicenter chart review of children whose uveitis was associated with juvenile idiopathic arthritis has identified three factors to help physicians target patients at risk of poor ocular outcomes.

“Sometimes the ophthalmologists are a little shy about pushing stronger immunomodulatory drugs. We were looking for predictors at onset so that … maybe we would know which kids are likely to have trouble and maybe get them started on stronger medications earlier,” the study's lead investigator, Richard J. Mier, M.D., said during a poster presentation at the 12th European Pediatric Rheumatology Congress.

Of the 44 children studied, 17 (39%) had serious eye problems during the 3 years after uveitis was detected. Despite the dual diagnosis, just 35% of the children who had poor ocular outcomes were receiving systemic immunomodulatory drugs.

The surprising finding was that “only a third was getting treatment,” Dr. Mier, director of pediatric services at Shriners Hospital for Children in Lexington, Ky., said in an interview.

“Our bottom line,” he added, “is that we are undertreating these kids, and what we really need to do is treat them more aggressively earlier.”

Dr. Mier and his coinvestigators defined poor ocular outcomes 36 months after diagnosis as acuity of 20/50 or less in one eye, three or more complications, or the need for ocular surgery. The study narrowed 17 potential risk factors at uveitis diagnosis to the following three predictors of poor ocular outcomes:

▸ Moderate or severe inflammation in one or both eyes.

▸ Eye inflammation symptoms such as pain, redness, photophobia, and tearing.

▸ Visual acuity of 20/50 or less in one or both eyes.

While uveitis is an eye inflammation, most children with juvenile idiopathic arthritis (JIA) do not present with eye symptoms, according to Dr. Mier. Typically, they are referred to an ophthalmologist for an eye exam after JIA is diagnosed because uveitis is a known comorbidity.

The children in the study were diagnosed with arthritis at 53 months of age on average and with uveitis more than a year later at 69 months.

At 36 months of follow-up, the most common ocular complications were synechiae, cataracts, glaucoma, and band keratopathy. About a third of the children (34%) required eye surgery.

Different centers use a variety of strategies for managing uveitis associated with JIA, according to Dr. Mier. The ideal is to have the pediatric rheumatologist collaborate with the ophthalmologist in treating the child, he said.

VERSAILLES, FRANCE — A multicenter chart review of children whose uveitis was associated with juvenile idiopathic arthritis has identified three factors to help physicians target patients at risk of poor ocular outcomes.

“Sometimes the ophthalmologists are a little shy about pushing stronger immunomodulatory drugs. We were looking for predictors at onset so that … maybe we would know which kids are likely to have trouble and maybe get them started on stronger medications earlier,” the study's lead investigator, Richard J. Mier, M.D., said during a poster presentation at the 12th European Pediatric Rheumatology Congress.

Of the 44 children studied, 17 (39%) had serious eye problems during the 3 years after uveitis was detected. Despite the dual diagnosis, just 35% of the children who had poor ocular outcomes were receiving systemic immunomodulatory drugs.

The surprising finding was that “only a third was getting treatment,” Dr. Mier, director of pediatric services at Shriners Hospital for Children in Lexington, Ky., said in an interview.

“Our bottom line,” he added, “is that we are undertreating these kids, and what we really need to do is treat them more aggressively earlier.”

Dr. Mier and his coinvestigators defined poor ocular outcomes 36 months after diagnosis as acuity of 20/50 or less in one eye, three or more complications, or the need for ocular surgery. The study narrowed 17 potential risk factors at uveitis diagnosis to the following three predictors of poor ocular outcomes:

▸ Moderate or severe inflammation in one or both eyes.

▸ Eye inflammation symptoms such as pain, redness, photophobia, and tearing.

▸ Visual acuity of 20/50 or less in one or both eyes.

While uveitis is an eye inflammation, most children with juvenile idiopathic arthritis (JIA) do not present with eye symptoms, according to Dr. Mier. Typically, they are referred to an ophthalmologist for an eye exam after JIA is diagnosed because uveitis is a known comorbidity.

The children in the study were diagnosed with arthritis at 53 months of age on average and with uveitis more than a year later at 69 months.

At 36 months of follow-up, the most common ocular complications were synechiae, cataracts, glaucoma, and band keratopathy. About a third of the children (34%) required eye surgery.

Different centers use a variety of strategies for managing uveitis associated with JIA, according to Dr. Mier. The ideal is to have the pediatric rheumatologist collaborate with the ophthalmologist in treating the child, he said.

VERSAILLES, FRANCE — A multicenter chart review of children whose uveitis was associated with juvenile idiopathic arthritis has identified three factors to help physicians target patients at risk of poor ocular outcomes.

“Sometimes the ophthalmologists are a little shy about pushing stronger immunomodulatory drugs. We were looking for predictors at onset so that … maybe we would know which kids are likely to have trouble and maybe get them started on stronger medications earlier,” the study's lead investigator, Richard J. Mier, M.D., said during a poster presentation at the 12th European Pediatric Rheumatology Congress.

Of the 44 children studied, 17 (39%) had serious eye problems during the 3 years after uveitis was detected. Despite the dual diagnosis, just 35% of the children who had poor ocular outcomes were receiving systemic immunomodulatory drugs.

The surprising finding was that “only a third was getting treatment,” Dr. Mier, director of pediatric services at Shriners Hospital for Children in Lexington, Ky., said in an interview.

“Our bottom line,” he added, “is that we are undertreating these kids, and what we really need to do is treat them more aggressively earlier.”

Dr. Mier and his coinvestigators defined poor ocular outcomes 36 months after diagnosis as acuity of 20/50 or less in one eye, three or more complications, or the need for ocular surgery. The study narrowed 17 potential risk factors at uveitis diagnosis to the following three predictors of poor ocular outcomes:

▸ Moderate or severe inflammation in one or both eyes.

▸ Eye inflammation symptoms such as pain, redness, photophobia, and tearing.

▸ Visual acuity of 20/50 or less in one or both eyes.

While uveitis is an eye inflammation, most children with juvenile idiopathic arthritis (JIA) do not present with eye symptoms, according to Dr. Mier. Typically, they are referred to an ophthalmologist for an eye exam after JIA is diagnosed because uveitis is a known comorbidity.

The children in the study were diagnosed with arthritis at 53 months of age on average and with uveitis more than a year later at 69 months.

At 36 months of follow-up, the most common ocular complications were synechiae, cataracts, glaucoma, and band keratopathy. About a third of the children (34%) required eye surgery.

Different centers use a variety of strategies for managing uveitis associated with JIA, according to Dr. Mier. The ideal is to have the pediatric rheumatologist collaborate with the ophthalmologist in treating the child, he said.

VERSAILLES, FRANCE — A surprisingly large proportion of children with juvenile idiopathic arthritis show clinical signs of temporomandibular joint arthritis and condylar damage, according to Belgian researchers who conducted thorough rheumatologic and dentofacial evaluations of 100 patients.

More than half, 55%, of the children had one or more signs of temporomandibular joint arthritis (TMJA). Eighty percent had condylar damage. The effects were seen across all subtypes of juvenile idiopathic arthritis (JIA).

An D. Billiau, M.D., and her colleagues at University Hospitals in Leuven reported their findings in a poster at the 12th European Pediatric Rheumatology Congress. Rheumatologists and orthodontists collaborated on the study, the findings of which indicate that clinical follow-up of every JIA patient should include “regular evaluation by an experienced orthodontist.”

The damage was more than what the team had expected, senior investigator Corinne Wouters, M.D., Ph.D., noted in an interview.

“Not enough” is being done to screen these children for TMJA, added Dr. Billiau, when asked whether rheumatologists check for TMJA after JIA diagnosis. Even when screening does occur, there is no agreement on how to detect early-stage TMJA.

The prevalence of TMJA in the JIA population is around 33%–67%, and the jaw disorder is associated with some, but not all, JIA subtypes, according to the medical literature, according to the investigators.

The study enrolled children from November 2003 to November 2004 in an outpatient clinic at University Hospital Gasthuisberg in Leuven. Girls outnumbered boys by nearly 2:1. The median age was 10.5 years, and upon first examination patients had a median disease duration of 3 years. Two-thirds of the population had active disease.

All patients underwent clinical rheumatologic examination and dentofacial evaluation. Forty-six patients consented to radiologic examinations, including, where feasible, a panoramic x-ray called an orthopantomogram and a lateral cephalogram. In 32 cases, the records were matched with those of healthy children who came to the clinic for minor orthodontic problems.

The most common clinical sign of TMJ arthritis was reported as reduced mouth opening in 28% of patients. This occurred more often in children with severe, active, or long-standing disease, but did not appear to differ among JIA subtypes.

Otherwise, the investigators reported that the signs and symptoms of TMJ arthritis as well as condylar lesions bore no relationship to disease characteristics such as duration, severity, activity, or subtype. “TMJ involvement and condylar damage can occur in every child with JIA, irrespective of JIA subtype,” they warned.

Compared with healthy children and children with minor orthodontic problems, they added that the JIA patients were found to have “a profoundly altered dentofacial profile.”

Yet routine orthodontic examination may not be sensitive enough to detect TMJ damage in the absence of clinical symptoms, according to Dr. Billiau's group. Warning of the aggressive course of TMJA, the investigators concluded that imaging would be needed for early diagnosis.

The next phase of the ongoing study is to determine the best imaging technique for diagnosing TMJA in children with JIA. Issues under consideration include sensitivity, feasibility, and safety, Dr. Wouters said.

VERSAILLES, FRANCE — A surprisingly large proportion of children with juvenile idiopathic arthritis show clinical signs of temporomandibular joint arthritis and condylar damage, according to Belgian researchers who conducted thorough rheumatologic and dentofacial evaluations of 100 patients.

More than half, 55%, of the children had one or more signs of temporomandibular joint arthritis (TMJA). Eighty percent had condylar damage. The effects were seen across all subtypes of juvenile idiopathic arthritis (JIA).

An D. Billiau, M.D., and her colleagues at University Hospitals in Leuven reported their findings in a poster at the 12th European Pediatric Rheumatology Congress. Rheumatologists and orthodontists collaborated on the study, the findings of which indicate that clinical follow-up of every JIA patient should include “regular evaluation by an experienced orthodontist.”

The damage was more than what the team had expected, senior investigator Corinne Wouters, M.D., Ph.D., noted in an interview.

“Not enough” is being done to screen these children for TMJA, added Dr. Billiau, when asked whether rheumatologists check for TMJA after JIA diagnosis. Even when screening does occur, there is no agreement on how to detect early-stage TMJA.

The prevalence of TMJA in the JIA population is around 33%–67%, and the jaw disorder is associated with some, but not all, JIA subtypes, according to the medical literature, according to the investigators.

The study enrolled children from November 2003 to November 2004 in an outpatient clinic at University Hospital Gasthuisberg in Leuven. Girls outnumbered boys by nearly 2:1. The median age was 10.5 years, and upon first examination patients had a median disease duration of 3 years. Two-thirds of the population had active disease.

All patients underwent clinical rheumatologic examination and dentofacial evaluation. Forty-six patients consented to radiologic examinations, including, where feasible, a panoramic x-ray called an orthopantomogram and a lateral cephalogram. In 32 cases, the records were matched with those of healthy children who came to the clinic for minor orthodontic problems.

The most common clinical sign of TMJ arthritis was reported as reduced mouth opening in 28% of patients. This occurred more often in children with severe, active, or long-standing disease, but did not appear to differ among JIA subtypes.

Otherwise, the investigators reported that the signs and symptoms of TMJ arthritis as well as condylar lesions bore no relationship to disease characteristics such as duration, severity, activity, or subtype. “TMJ involvement and condylar damage can occur in every child with JIA, irrespective of JIA subtype,” they warned.

Compared with healthy children and children with minor orthodontic problems, they added that the JIA patients were found to have “a profoundly altered dentofacial profile.”

Yet routine orthodontic examination may not be sensitive enough to detect TMJ damage in the absence of clinical symptoms, according to Dr. Billiau's group. Warning of the aggressive course of TMJA, the investigators concluded that imaging would be needed for early diagnosis.

The next phase of the ongoing study is to determine the best imaging technique for diagnosing TMJA in children with JIA. Issues under consideration include sensitivity, feasibility, and safety, Dr. Wouters said.

VERSAILLES, FRANCE — A surprisingly large proportion of children with juvenile idiopathic arthritis show clinical signs of temporomandibular joint arthritis and condylar damage, according to Belgian researchers who conducted thorough rheumatologic and dentofacial evaluations of 100 patients.

More than half, 55%, of the children had one or more signs of temporomandibular joint arthritis (TMJA). Eighty percent had condylar damage. The effects were seen across all subtypes of juvenile idiopathic arthritis (JIA).

An D. Billiau, M.D., and her colleagues at University Hospitals in Leuven reported their findings in a poster at the 12th European Pediatric Rheumatology Congress. Rheumatologists and orthodontists collaborated on the study, the findings of which indicate that clinical follow-up of every JIA patient should include “regular evaluation by an experienced orthodontist.”

The damage was more than what the team had expected, senior investigator Corinne Wouters, M.D., Ph.D., noted in an interview.

“Not enough” is being done to screen these children for TMJA, added Dr. Billiau, when asked whether rheumatologists check for TMJA after JIA diagnosis. Even when screening does occur, there is no agreement on how to detect early-stage TMJA.

The prevalence of TMJA in the JIA population is around 33%–67%, and the jaw disorder is associated with some, but not all, JIA subtypes, according to the medical literature, according to the investigators.

The study enrolled children from November 2003 to November 2004 in an outpatient clinic at University Hospital Gasthuisberg in Leuven. Girls outnumbered boys by nearly 2:1. The median age was 10.5 years, and upon first examination patients had a median disease duration of 3 years. Two-thirds of the population had active disease.

All patients underwent clinical rheumatologic examination and dentofacial evaluation. Forty-six patients consented to radiologic examinations, including, where feasible, a panoramic x-ray called an orthopantomogram and a lateral cephalogram. In 32 cases, the records were matched with those of healthy children who came to the clinic for minor orthodontic problems.

The most common clinical sign of TMJ arthritis was reported as reduced mouth opening in 28% of patients. This occurred more often in children with severe, active, or long-standing disease, but did not appear to differ among JIA subtypes.

Otherwise, the investigators reported that the signs and symptoms of TMJ arthritis as well as condylar lesions bore no relationship to disease characteristics such as duration, severity, activity, or subtype. “TMJ involvement and condylar damage can occur in every child with JIA, irrespective of JIA subtype,” they warned.

Compared with healthy children and children with minor orthodontic problems, they added that the JIA patients were found to have “a profoundly altered dentofacial profile.”

Yet routine orthodontic examination may not be sensitive enough to detect TMJ damage in the absence of clinical symptoms, according to Dr. Billiau's group. Warning of the aggressive course of TMJA, the investigators concluded that imaging would be needed for early diagnosis.

The next phase of the ongoing study is to determine the best imaging technique for diagnosing TMJA in children with JIA. Issues under consideration include sensitivity, feasibility, and safety, Dr. Wouters said.

VERSAILLES, FRANCE — Physicians should stop dismissing nighttime lower limb pain in children as just growing pains, Raju P. Khubchandani, M.D., told attendees at the annual scientific meeting of the 12th European Pediatric Rheumatology Congress.

Such nighttime lower limb pain is a syndrome with multiple causes, the most common of which is likely hypermobility, according to Dr. Khubchandani of Jaslok Hospital and Research Centre in Mumbai, India.

Dr. Khubchandani, a pediatrician and consultant in pediatric rheumatology, urged that the label growing pains be changed to a more medical term with a catchy acronym, so that clinicians will take the children's complaints seriously.

“Even parents have stopped perceiving that 'growth' is responsible,” he said, characterizing growing pains as “a big but neglected issue” around the globe.

Presenting the findings from an investigation of 448 middle-income children in a Mumbai elementary school, Dr. Khubchandani reported that 28.1% suffered from lower limb pain at night. Prevalence rates in studies from other countries have ranged from 4.2% to 38%, he said, attributing the variation in part to different diagnostic criteria.

Dr. Khubchandani and his co-investigator Vijay Viswanathan, M.D., also of Jaslok Hospital, included intermittent pain and pain that lasted at least 3 months in the past in their criteria. Only bilateral, nonarticular, lower limb pain was considered. It had to occur in late evening or overnight with the child well by morning.

The criteria also required a normal physical exam with normal laboratory work and x-rays when available. Children with neuromusculoskeletal disorders were excluded.

Prevalence of growing pains ranged from 22% of children at age 6 years to 35% at age 9 in the Mumbai study, which assessed children aged 4–10 years. About a quarter of the boys (57/226) and nearly a third of the girls (69/222) presented with the condition.

The most common site was the calf (51%) followed by the anterior thigh (25%) and behind the knee (24%). In addition, 38% of children with growing pains complained of abdominal pain, 21% of headache, and 21% of sleep disturbances.

Hypermobility was so common among children presenting with growing pains that the investigators recommended in a poster that children presenting with growing pains be screened for that condition as well.

The school population included 98 children with hypermobility and growing pains. Another 139 had hypermobility without growing pains; only 28 had growing pains without hypermobility. The remaining 183 children had neither.

Other possible causes include restless legs, hyperactivity, emotional factors, fatigue, and anatomic defects, according to Dr. Khubchandani.

About a quarter of the children had a family member with a rheumatologic condition, leading him to speculate that some might have been using the adult as a behavioral model.

“This is not one entity. There are several things that can cause this syndrome,” he said in an interview after his talk.

“Any kid who comes with this syndrome, we automatically make a preconceived diagnosis,” he said. “We tell them it is growing pains. It will go away. We should evaluate further.”

Parents do take the condition seriously, according to Dr. Khubchandani. About 86% of the parents in the Mumbai investigation stayed up at night to massage their children's legs, while 10% gave a “warm fomentation” and the rest did both. “There was no parent who thought they should do nothing about it,” Dr. Khubchandani noted.

From the parents' points of view, the leading explanations were nutrition (34%), overexertion (29%), and calcium deficiency (26%).

Six percent thought their children had rheumatism. Only 3% attributed the pains to growth and even fewer, 2%, to attention seeking.

Dr. Khubchandani said that one of his concerns is that children are given unnecessary nutrients and calcium supplements in the absence of medical attention. “Mere reassurance does not prevent parents from acting,” he warned.

“Our 'no action' advice is considered as inaction.”

VERSAILLES, FRANCE — Physicians should stop dismissing nighttime lower limb pain in children as just growing pains, Raju P. Khubchandani, M.D., told attendees at the annual scientific meeting of the 12th European Pediatric Rheumatology Congress.

Such nighttime lower limb pain is a syndrome with multiple causes, the most common of which is likely hypermobility, according to Dr. Khubchandani of Jaslok Hospital and Research Centre in Mumbai, India.

Dr. Khubchandani, a pediatrician and consultant in pediatric rheumatology, urged that the label growing pains be changed to a more medical term with a catchy acronym, so that clinicians will take the children's complaints seriously.

“Even parents have stopped perceiving that 'growth' is responsible,” he said, characterizing growing pains as “a big but neglected issue” around the globe.

Presenting the findings from an investigation of 448 middle-income children in a Mumbai elementary school, Dr. Khubchandani reported that 28.1% suffered from lower limb pain at night. Prevalence rates in studies from other countries have ranged from 4.2% to 38%, he said, attributing the variation in part to different diagnostic criteria.

Dr. Khubchandani and his co-investigator Vijay Viswanathan, M.D., also of Jaslok Hospital, included intermittent pain and pain that lasted at least 3 months in the past in their criteria. Only bilateral, nonarticular, lower limb pain was considered. It had to occur in late evening or overnight with the child well by morning.

The criteria also required a normal physical exam with normal laboratory work and x-rays when available. Children with neuromusculoskeletal disorders were excluded.

Prevalence of growing pains ranged from 22% of children at age 6 years to 35% at age 9 in the Mumbai study, which assessed children aged 4–10 years. About a quarter of the boys (57/226) and nearly a third of the girls (69/222) presented with the condition.

The most common site was the calf (51%) followed by the anterior thigh (25%) and behind the knee (24%). In addition, 38% of children with growing pains complained of abdominal pain, 21% of headache, and 21% of sleep disturbances.

Hypermobility was so common among children presenting with growing pains that the investigators recommended in a poster that children presenting with growing pains be screened for that condition as well.

The school population included 98 children with hypermobility and growing pains. Another 139 had hypermobility without growing pains; only 28 had growing pains without hypermobility. The remaining 183 children had neither.

Other possible causes include restless legs, hyperactivity, emotional factors, fatigue, and anatomic defects, according to Dr. Khubchandani.

About a quarter of the children had a family member with a rheumatologic condition, leading him to speculate that some might have been using the adult as a behavioral model.

“This is not one entity. There are several things that can cause this syndrome,” he said in an interview after his talk.

“Any kid who comes with this syndrome, we automatically make a preconceived diagnosis,” he said. “We tell them it is growing pains. It will go away. We should evaluate further.”

Parents do take the condition seriously, according to Dr. Khubchandani. About 86% of the parents in the Mumbai investigation stayed up at night to massage their children's legs, while 10% gave a “warm fomentation” and the rest did both. “There was no parent who thought they should do nothing about it,” Dr. Khubchandani noted.

From the parents' points of view, the leading explanations were nutrition (34%), overexertion (29%), and calcium deficiency (26%).

Six percent thought their children had rheumatism. Only 3% attributed the pains to growth and even fewer, 2%, to attention seeking.

Dr. Khubchandani said that one of his concerns is that children are given unnecessary nutrients and calcium supplements in the absence of medical attention. “Mere reassurance does not prevent parents from acting,” he warned.

“Our 'no action' advice is considered as inaction.”

VERSAILLES, FRANCE — Physicians should stop dismissing nighttime lower limb pain in children as just growing pains, Raju P. Khubchandani, M.D., told attendees at the annual scientific meeting of the 12th European Pediatric Rheumatology Congress.

Such nighttime lower limb pain is a syndrome with multiple causes, the most common of which is likely hypermobility, according to Dr. Khubchandani of Jaslok Hospital and Research Centre in Mumbai, India.

Dr. Khubchandani, a pediatrician and consultant in pediatric rheumatology, urged that the label growing pains be changed to a more medical term with a catchy acronym, so that clinicians will take the children's complaints seriously.

“Even parents have stopped perceiving that 'growth' is responsible,” he said, characterizing growing pains as “a big but neglected issue” around the globe.

Presenting the findings from an investigation of 448 middle-income children in a Mumbai elementary school, Dr. Khubchandani reported that 28.1% suffered from lower limb pain at night. Prevalence rates in studies from other countries have ranged from 4.2% to 38%, he said, attributing the variation in part to different diagnostic criteria.

Dr. Khubchandani and his co-investigator Vijay Viswanathan, M.D., also of Jaslok Hospital, included intermittent pain and pain that lasted at least 3 months in the past in their criteria. Only bilateral, nonarticular, lower limb pain was considered. It had to occur in late evening or overnight with the child well by morning.

The criteria also required a normal physical exam with normal laboratory work and x-rays when available. Children with neuromusculoskeletal disorders were excluded.

Prevalence of growing pains ranged from 22% of children at age 6 years to 35% at age 9 in the Mumbai study, which assessed children aged 4–10 years. About a quarter of the boys (57/226) and nearly a third of the girls (69/222) presented with the condition.

The most common site was the calf (51%) followed by the anterior thigh (25%) and behind the knee (24%). In addition, 38% of children with growing pains complained of abdominal pain, 21% of headache, and 21% of sleep disturbances.

Hypermobility was so common among children presenting with growing pains that the investigators recommended in a poster that children presenting with growing pains be screened for that condition as well.

The school population included 98 children with hypermobility and growing pains. Another 139 had hypermobility without growing pains; only 28 had growing pains without hypermobility. The remaining 183 children had neither.

Other possible causes include restless legs, hyperactivity, emotional factors, fatigue, and anatomic defects, according to Dr. Khubchandani.

About a quarter of the children had a family member with a rheumatologic condition, leading him to speculate that some might have been using the adult as a behavioral model.

“This is not one entity. There are several things that can cause this syndrome,” he said in an interview after his talk.

“Any kid who comes with this syndrome, we automatically make a preconceived diagnosis,” he said. “We tell them it is growing pains. It will go away. We should evaluate further.”

Parents do take the condition seriously, according to Dr. Khubchandani. About 86% of the parents in the Mumbai investigation stayed up at night to massage their children's legs, while 10% gave a “warm fomentation” and the rest did both. “There was no parent who thought they should do nothing about it,” Dr. Khubchandani noted.

From the parents' points of view, the leading explanations were nutrition (34%), overexertion (29%), and calcium deficiency (26%).

Six percent thought their children had rheumatism. Only 3% attributed the pains to growth and even fewer, 2%, to attention seeking.

Dr. Khubchandani said that one of his concerns is that children are given unnecessary nutrients and calcium supplements in the absence of medical attention. “Mere reassurance does not prevent parents from acting,” he warned.

“Our 'no action' advice is considered as inaction.”

Pneumonia Study Leads Top 10 Journal Articles on Pediatric Infectious Diseases

ASPEN, COLO. — A World Health Organization study conducted in eight developing countries tops an expert's annual list of the most important journal articles for physicians treating pediatric infectious diseases.

“Basically, what it showed was, in a child with pneumonia who is not toxic, you never need to treat with an IV. You can treat orally,” Michael Radetsky, M.D., said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

The nonblinded study (Lancet 2004;364:1141–8) randomized 1,702 children, aged 3–59 months, who were hospitalized with severe pneumonia. About half received oral amoxicillin for 48 hours; the rest were given parenteral penicillin.

Both regimens in the study—oral and injectable—had the same rate of treatment failure: 19% at 48 hours.

Emmanuel Addo-Yobo, M.D., of the Amoxicillin Penicillin Pneumonia International Study group interpreted the outcome as evidence that oral amoxicillin is equivalent to injectable penicillin.

Dr. Radetsky, a consultant in pediatric infectious diseases and clinical professor at the University of New Mexico in Albuquerque, also recommended the following articles:

Sensitivity of Rapid Strep Tests

M. Bruce Edmonson, M.D., and Kathryn R. Farwell at the University of Wisconsin Medical School in Madison reviewed 1,184 consecutive Rapid Antigen Detection Tests in a single pediatric clinic (Pediatrics 2005;115:280–5).

Their study compared test results to the pretest clinical likelihood of group A streptococcal pharyngitis, as calculated in a blinded chart review.

The investigators found the test's sensitivity reflected the likelihood that a patient had a group A infection. Sensitivity was high in patients younger than 15 years of age who had tonsillar exudate without a cough. It was low in patients with a McIsaac score of 2 or less.

“The accuracy of a rapid strep test goes up when you think they have strep throat. The accuracy goes down when you don't think it is strep. So it's not a good test to do in the in-between child,” Dr. Radetsky said, advising physicians to skip the test and order a culture when they are wavering or responding to circumstances, such as a sibling infected the previous week.

Infant Hyperpyrexia

Hyperpyrexia is a rare event that might be a risk factor for serious bacterial infection in infants less than 3 months old, according to Rachel Stanley, M.D. (Pediatr. Emerg. Care 2005;21:291–4).

Dr. Stanley of the University of Michigan, Ann Arbor, and her coauthors from Children's Hospital, Boston, reviewed 5,279 infants younger than 3 months who were brought to an urban emergency department with triage temperatures of 38° C or higher. Only 98 patients (1.7%) had hyperpyrexia, which was defined as a rectal temperature of 40° C or greater. More than a third of that group, 35 infants, was diagnosed with serious bacterial infections, the most common of which was urinary tract infections in 24 infants.

The authors suggested that future management algorithms might list high fever as a risk factor for serious infection. Managing high fevers in young infants is a challenge that keeps physicians awake at night, according to Dr. Radetsky. “I love this article because it takes this fear and gives body to the fear,” he said. “It says, yes, you should be concerned about it … and, yes, children can be seriously ill, but it's very rare.”

New Acute Otitis Media Paradigm

Because 80% of acute otitis media infections respond spontaneously, some physicians have called on their colleagues to delay antibiotics for 3 days in selected children who are assured clinical follow-up. Thomas F.X. Fisher, M.D., of the State University of New York at Stony Brook, and his coauthors surveyed 654 parents and 84 pediatricians about the proposed paradigm (Pediatr. Emerg. Care 2005;21:170–2).

The researchers found 53% of the parents and 73% of the physicians were “somewhat comfortable to very comfortable” with deferring antibiotics. Comfort levels increased with knowledge of the evidence, but 61% of parents did not know antibiotics could have adverse effects; 72% did not know research supported selective use of antibiotics.

Although many physicians and parents appeared open to the new recommendations, the authors noted that half the pediatricians routinely prescribed antibiotics for all cases of acute otitis media.

“What this means is, we have some work to do,” Dr. Radetsky said, calling for greater effort to educate physicians and parents. Nonetheless, he described himself as heartened by the level of physician acceptance: “It's miraculous.”

Antipyretic Effects on Measured Fever

Febrile infants often receive antipyretics at home before being brought to the emergency department, according to a prospective study that enrolled 474 infants with fever or a history of fever from Aug. 24, 2000 to Dec. 31, 2001 (Arch. Pediatr. Adolesc. Med. 2004;158:972–6).

Investigators Shirley Y. Huang, M.D., and David S. Greenes, M.D., of Children's Hospital in Boston were surprised to find significantly higher measured temperatures in 187 infants who had been given antipyretics before arriving in the emergency department, compared with 287 infants who had not been pretreated.

Although parents reported giving fever reducers to 40% of study population, it turned out that the doses often were inadequate. Only 10% had received a therapeutic dose 1–5 hours prior to coming to the emergency department, according to the authors. Dr. Radetsky said the article addresses a common conundrum: how to manage a child after a parent reports antipyretic use.

“The results of the article are that even if you have a history of having Motrin or Tylenol, it doesn't alter what you measure,” he said. “You can trust your measurement. No fever is no fever. The management decision should depend on what you measure at the time you do the evaluation.”

Pulse Oximetry, Bronchiolitis Discharge

Dependence on pulse oximetry readings can delay discharge of infants hospitalized for bronchiolitis, reported Alan R. Schroeder, M.D., and his associates at the University of California, San Francisco (Arch. Pediatr. Adolesc. Med. 2004;158:527–30).

The retrospective chart study found 16 of 62 infants were kept in the hospital an average of 1.6 days until they reached a pulse oximetry goal despite having met all other criteria for discharge. The authors detected trends toward younger age, lower oxygen saturations at admission and discharge, and increased number of cutoffs in oxygen saturation among the patients with prolonged stays.

They could not determine whether the prolonged stays were beneficial or harmful, however. They noted wide variability among institutions in the setting of minimum saturation levels.

Dr. Radetsky warned against “the tyranny of the continuous pulse oximeter.” He said pediatricians should use it in the office when deciding whether to hospitalize a patient; once the infant is admitted, however, he said to use it sparingly, especially in stable or improving patients.

“When you should give oxygen and when you should discharge, no one knows,” he said, adding that physicians should “avoid entrapment by data that has no clinical importance.”

Diarrhea Etiology Elusive

Stool testing turned up a bacterial pathogen in just 12 (5.3%) of 226 Seattle children enrolled in a prospective study of diarrhea in pediatric outpatient settings (Pediatr. Infect. Dis. J. 2005;24:142–8). Additional screening of smaller subgroups identified 1 child with a parasite, 8 with Clostridium difficile toxin, and 16 with viruses.

Donna M. Denno, M.D., of the University of Washington, Seattle, and her associates reported comparable results from two study sites: a private practice and a clinic in a municipal hospital serving a largely immigrant population.

The investigators associated bacterial infection with visible fecal blood, increased stool frequency, abdominal tenderness, and white or red cells in the stool. They noted, however, that 75% of children without a bacterial infection had at least one of these risk factors. Their conclusion: “Exclusion criteria for stool testing in diarrhea remain elusive.” Dr. Radetsky said that in most patients, conventional laboratory testing did not turn up a cause. His conclusion: “Stool cultures are infrequently needed in ambulatory practice.”

New Treatment for Head Lice

Dale Lawrence Pearlman, M.D., a dermatologist in Menlo Park, Calif., reported a 96% cure rate and 94% remission rate in two open clinical trials of a new treatment for head lice (Pediatrics 2004;114:e275–9).

Dr. Pearlman holds patents for Nuvo lotion, which he tested in 133 children recruited as being hard to treat. He declared Nuvo lotion to be the first in a new class of nontoxic lotions that he called dry-on, suffocation-based pediculides.

The report has drawn an accusation of hype (Lancet 2005;365:8–10), and the product has been likened to hair conditioner, according to Dr. Radetsky. Nonetheless, he held out hope that controlled trials could prove it to be “the up-and-coming treatment of choice.”

A new treatment is needed, he said. “Things are not going well for those of us that treat head lice. The success rate is going down. There are failures for head lice all over the place.”

A Bacterial Cause of Conjunctivitis?

Investigators from the University of Amsterdam in the Netherlands have come up with a scoring system for predicting a positive bacterial culture in a patient with conjunctivitis (BMJ 2004;329:206–10).

General practitioner Remco P. Rietveld, M.D., and his colleagues have proposed point values for glued eyes in the morning, itch, and history of conjunctivitis. Physicians use a patient's total points, based on a scale of −3 to +5, to calculate the probability of the patient testing positive. Though widely used, purulent secretion is almost diagnostically noninformative, the investigators said.

The cohort study was based on 184 adult patients enrolled from September 1999 to December 2002. Only about a third had a positive culture.

Dr. Radetsky said he included this article in his top 10 list because “there is no pediatric study that helps a practitioner to decide whether something is bacterial conjunctivitis or not.”

A similar study of children is needed, he said. Until one is done, this system enables physicians to reduce the use of topical antibiotics, based on the historical information provided.

Pneumonia Study Leads Top 10 Journal Articles on Pediatric Infectious Diseases

ASPEN, COLO. — A World Health Organization study conducted in eight developing countries tops an expert's annual list of the most important journal articles for physicians treating pediatric infectious diseases.

“Basically, what it showed was, in a child with pneumonia who is not toxic, you never need to treat with an IV. You can treat orally,” Michael Radetsky, M.D., said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

The nonblinded study (Lancet 2004;364:1141–8) randomized 1,702 children, aged 3–59 months, who were hospitalized with severe pneumonia. About half received oral amoxicillin for 48 hours; the rest were given parenteral penicillin.

Both regimens in the study—oral and injectable—had the same rate of treatment failure: 19% at 48 hours.

Emmanuel Addo-Yobo, M.D., of the Amoxicillin Penicillin Pneumonia International Study group interpreted the outcome as evidence that oral amoxicillin is equivalent to injectable penicillin.

Dr. Radetsky, a consultant in pediatric infectious diseases and clinical professor at the University of New Mexico in Albuquerque, also recommended the following articles:

Sensitivity of Rapid Strep Tests

M. Bruce Edmonson, M.D., and Kathryn R. Farwell at the University of Wisconsin Medical School in Madison reviewed 1,184 consecutive Rapid Antigen Detection Tests in a single pediatric clinic (Pediatrics 2005;115:280–5).

Their study compared test results to the pretest clinical likelihood of group A streptococcal pharyngitis, as calculated in a blinded chart review.

The investigators found the test's sensitivity reflected the likelihood that a patient had a group A infection. Sensitivity was high in patients younger than 15 years of age who had tonsillar exudate without a cough. It was low in patients with a McIsaac score of 2 or less.

“The accuracy of a rapid strep test goes up when you think they have strep throat. The accuracy goes down when you don't think it is strep. So it's not a good test to do in the in-between child,” Dr. Radetsky said, advising physicians to skip the test and order a culture when they are wavering or responding to circumstances, such as a sibling infected the previous week.

Infant Hyperpyrexia

Hyperpyrexia is a rare event that might be a risk factor for serious bacterial infection in infants less than 3 months old, according to Rachel Stanley, M.D. (Pediatr. Emerg. Care 2005;21:291–4).

Dr. Stanley of the University of Michigan, Ann Arbor, and her coauthors from Children's Hospital, Boston, reviewed 5,279 infants younger than 3 months who were brought to an urban emergency department with triage temperatures of 38° C or higher. Only 98 patients (1.7%) had hyperpyrexia, which was defined as a rectal temperature of 40° C or greater. More than a third of that group, 35 infants, was diagnosed with serious bacterial infections, the most common of which was urinary tract infections in 24 infants.

The authors suggested that future management algorithms might list high fever as a risk factor for serious infection. Managing high fevers in young infants is a challenge that keeps physicians awake at night, according to Dr. Radetsky. “I love this article because it takes this fear and gives body to the fear,” he said. “It says, yes, you should be concerned about it … and, yes, children can be seriously ill, but it's very rare.”

New Acute Otitis Media Paradigm

Because 80% of acute otitis media infections respond spontaneously, some physicians have called on their colleagues to delay antibiotics for 3 days in selected children who are assured clinical follow-up. Thomas F.X. Fisher, M.D., of the State University of New York at Stony Brook, and his coauthors surveyed 654 parents and 84 pediatricians about the proposed paradigm (Pediatr. Emerg. Care 2005;21:170–2).

The researchers found 53% of the parents and 73% of the physicians were “somewhat comfortable to very comfortable” with deferring antibiotics. Comfort levels increased with knowledge of the evidence, but 61% of parents did not know antibiotics could have adverse effects; 72% did not know research supported selective use of antibiotics.

Although many physicians and parents appeared open to the new recommendations, the authors noted that half the pediatricians routinely prescribed antibiotics for all cases of acute otitis media.

“What this means is, we have some work to do,” Dr. Radetsky said, calling for greater effort to educate physicians and parents. Nonetheless, he described himself as heartened by the level of physician acceptance: “It's miraculous.”

Antipyretic Effects on Measured Fever

Febrile infants often receive antipyretics at home before being brought to the emergency department, according to a prospective study that enrolled 474 infants with fever or a history of fever from Aug. 24, 2000 to Dec. 31, 2001 (Arch. Pediatr. Adolesc. Med. 2004;158:972–6).

Investigators Shirley Y. Huang, M.D., and David S. Greenes, M.D., of Children's Hospital in Boston were surprised to find significantly higher measured temperatures in 187 infants who had been given antipyretics before arriving in the emergency department, compared with 287 infants who had not been pretreated.

Although parents reported giving fever reducers to 40% of study population, it turned out that the doses often were inadequate. Only 10% had received a therapeutic dose 1–5 hours prior to coming to the emergency department, according to the authors. Dr. Radetsky said the article addresses a common conundrum: how to manage a child after a parent reports antipyretic use.

“The results of the article are that even if you have a history of having Motrin or Tylenol, it doesn't alter what you measure,” he said. “You can trust your measurement. No fever is no fever. The management decision should depend on what you measure at the time you do the evaluation.”

Pulse Oximetry, Bronchiolitis Discharge

Dependence on pulse oximetry readings can delay discharge of infants hospitalized for bronchiolitis, reported Alan R. Schroeder, M.D., and his associates at the University of California, San Francisco (Arch. Pediatr. Adolesc. Med. 2004;158:527–30).

The retrospective chart study found 16 of 62 infants were kept in the hospital an average of 1.6 days until they reached a pulse oximetry goal despite having met all other criteria for discharge. The authors detected trends toward younger age, lower oxygen saturations at admission and discharge, and increased number of cutoffs in oxygen saturation among the patients with prolonged stays.

They could not determine whether the prolonged stays were beneficial or harmful, however. They noted wide variability among institutions in the setting of minimum saturation levels.

Dr. Radetsky warned against “the tyranny of the continuous pulse oximeter.” He said pediatricians should use it in the office when deciding whether to hospitalize a patient; once the infant is admitted, however, he said to use it sparingly, especially in stable or improving patients.

“When you should give oxygen and when you should discharge, no one knows,” he said, adding that physicians should “avoid entrapment by data that has no clinical importance.”

Diarrhea Etiology Elusive

Stool testing turned up a bacterial pathogen in just 12 (5.3%) of 226 Seattle children enrolled in a prospective study of diarrhea in pediatric outpatient settings (Pediatr. Infect. Dis. J. 2005;24:142–8). Additional screening of smaller subgroups identified 1 child with a parasite, 8 with Clostridium difficile toxin, and 16 with viruses.

Donna M. Denno, M.D., of the University of Washington, Seattle, and her associates reported comparable results from two study sites: a private practice and a clinic in a municipal hospital serving a largely immigrant population.

The investigators associated bacterial infection with visible fecal blood, increased stool frequency, abdominal tenderness, and white or red cells in the stool. They noted, however, that 75% of children without a bacterial infection had at least one of these risk factors. Their conclusion: “Exclusion criteria for stool testing in diarrhea remain elusive.” Dr. Radetsky said that in most patients, conventional laboratory testing did not turn up a cause. His conclusion: “Stool cultures are infrequently needed in ambulatory practice.”

New Treatment for Head Lice

Dale Lawrence Pearlman, M.D., a dermatologist in Menlo Park, Calif., reported a 96% cure rate and 94% remission rate in two open clinical trials of a new treatment for head lice (Pediatrics 2004;114:e275–9).

Dr. Pearlman holds patents for Nuvo lotion, which he tested in 133 children recruited as being hard to treat. He declared Nuvo lotion to be the first in a new class of nontoxic lotions that he called dry-on, suffocation-based pediculides.

The report has drawn an accusation of hype (Lancet 2005;365:8–10), and the product has been likened to hair conditioner, according to Dr. Radetsky. Nonetheless, he held out hope that controlled trials could prove it to be “the up-and-coming treatment of choice.”

A new treatment is needed, he said. “Things are not going well for those of us that treat head lice. The success rate is going down. There are failures for head lice all over the place.”

A Bacterial Cause of Conjunctivitis?

Investigators from the University of Amsterdam in the Netherlands have come up with a scoring system for predicting a positive bacterial culture in a patient with conjunctivitis (BMJ 2004;329:206–10).

General practitioner Remco P. Rietveld, M.D., and his colleagues have proposed point values for glued eyes in the morning, itch, and history of conjunctivitis. Physicians use a patient's total points, based on a scale of −3 to +5, to calculate the probability of the patient testing positive. Though widely used, purulent secretion is almost diagnostically noninformative, the investigators said.

The cohort study was based on 184 adult patients enrolled from September 1999 to December 2002. Only about a third had a positive culture.

Dr. Radetsky said he included this article in his top 10 list because “there is no pediatric study that helps a practitioner to decide whether something is bacterial conjunctivitis or not.”

A similar study of children is needed, he said. Until one is done, this system enables physicians to reduce the use of topical antibiotics, based on the historical information provided.

Pneumonia Study Leads Top 10 Journal Articles on Pediatric Infectious Diseases

ASPEN, COLO. — A World Health Organization study conducted in eight developing countries tops an expert's annual list of the most important journal articles for physicians treating pediatric infectious diseases.

“Basically, what it showed was, in a child with pneumonia who is not toxic, you never need to treat with an IV. You can treat orally,” Michael Radetsky, M.D., said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

The nonblinded study (Lancet 2004;364:1141–8) randomized 1,702 children, aged 3–59 months, who were hospitalized with severe pneumonia. About half received oral amoxicillin for 48 hours; the rest were given parenteral penicillin.

Both regimens in the study—oral and injectable—had the same rate of treatment failure: 19% at 48 hours.

Emmanuel Addo-Yobo, M.D., of the Amoxicillin Penicillin Pneumonia International Study group interpreted the outcome as evidence that oral amoxicillin is equivalent to injectable penicillin.

Dr. Radetsky, a consultant in pediatric infectious diseases and clinical professor at the University of New Mexico in Albuquerque, also recommended the following articles:

Sensitivity of Rapid Strep Tests

M. Bruce Edmonson, M.D., and Kathryn R. Farwell at the University of Wisconsin Medical School in Madison reviewed 1,184 consecutive Rapid Antigen Detection Tests in a single pediatric clinic (Pediatrics 2005;115:280–5).

Their study compared test results to the pretest clinical likelihood of group A streptococcal pharyngitis, as calculated in a blinded chart review.

The investigators found the test's sensitivity reflected the likelihood that a patient had a group A infection. Sensitivity was high in patients younger than 15 years of age who had tonsillar exudate without a cough. It was low in patients with a McIsaac score of 2 or less.

“The accuracy of a rapid strep test goes up when you think they have strep throat. The accuracy goes down when you don't think it is strep. So it's not a good test to do in the in-between child,” Dr. Radetsky said, advising physicians to skip the test and order a culture when they are wavering or responding to circumstances, such as a sibling infected the previous week.

Infant Hyperpyrexia

Hyperpyrexia is a rare event that might be a risk factor for serious bacterial infection in infants less than 3 months old, according to Rachel Stanley, M.D. (Pediatr. Emerg. Care 2005;21:291–4).

Dr. Stanley of the University of Michigan, Ann Arbor, and her coauthors from Children's Hospital, Boston, reviewed 5,279 infants younger than 3 months who were brought to an urban emergency department with triage temperatures of 38° C or higher. Only 98 patients (1.7%) had hyperpyrexia, which was defined as a rectal temperature of 40° C or greater. More than a third of that group, 35 infants, was diagnosed with serious bacterial infections, the most common of which was urinary tract infections in 24 infants.

The authors suggested that future management algorithms might list high fever as a risk factor for serious infection. Managing high fevers in young infants is a challenge that keeps physicians awake at night, according to Dr. Radetsky. “I love this article because it takes this fear and gives body to the fear,” he said. “It says, yes, you should be concerned about it … and, yes, children can be seriously ill, but it's very rare.”

New Acute Otitis Media Paradigm

Because 80% of acute otitis media infections respond spontaneously, some physicians have called on their colleagues to delay antibiotics for 3 days in selected children who are assured clinical follow-up. Thomas F.X. Fisher, M.D., of the State University of New York at Stony Brook, and his coauthors surveyed 654 parents and 84 pediatricians about the proposed paradigm (Pediatr. Emerg. Care 2005;21:170–2).

The researchers found 53% of the parents and 73% of the physicians were “somewhat comfortable to very comfortable” with deferring antibiotics. Comfort levels increased with knowledge of the evidence, but 61% of parents did not know antibiotics could have adverse effects; 72% did not know research supported selective use of antibiotics.

Although many physicians and parents appeared open to the new recommendations, the authors noted that half the pediatricians routinely prescribed antibiotics for all cases of acute otitis media.

“What this means is, we have some work to do,” Dr. Radetsky said, calling for greater effort to educate physicians and parents. Nonetheless, he described himself as heartened by the level of physician acceptance: “It's miraculous.”

Antipyretic Effects on Measured Fever

Febrile infants often receive antipyretics at home before being brought to the emergency department, according to a prospective study that enrolled 474 infants with fever or a history of fever from Aug. 24, 2000 to Dec. 31, 2001 (Arch. Pediatr. Adolesc. Med. 2004;158:972–6).

Investigators Shirley Y. Huang, M.D., and David S. Greenes, M.D., of Children's Hospital in Boston were surprised to find significantly higher measured temperatures in 187 infants who had been given antipyretics before arriving in the emergency department, compared with 287 infants who had not been pretreated.

Although parents reported giving fever reducers to 40% of study population, it turned out that the doses often were inadequate. Only 10% had received a therapeutic dose 1–5 hours prior to coming to the emergency department, according to the authors. Dr. Radetsky said the article addresses a common conundrum: how to manage a child after a parent reports antipyretic use.

“The results of the article are that even if you have a history of having Motrin or Tylenol, it doesn't alter what you measure,” he said. “You can trust your measurement. No fever is no fever. The management decision should depend on what you measure at the time you do the evaluation.”

Pulse Oximetry, Bronchiolitis Discharge

Dependence on pulse oximetry readings can delay discharge of infants hospitalized for bronchiolitis, reported Alan R. Schroeder, M.D., and his associates at the University of California, San Francisco (Arch. Pediatr. Adolesc. Med. 2004;158:527–30).

The retrospective chart study found 16 of 62 infants were kept in the hospital an average of 1.6 days until they reached a pulse oximetry goal despite having met all other criteria for discharge. The authors detected trends toward younger age, lower oxygen saturations at admission and discharge, and increased number of cutoffs in oxygen saturation among the patients with prolonged stays.

They could not determine whether the prolonged stays were beneficial or harmful, however. They noted wide variability among institutions in the setting of minimum saturation levels.

Dr. Radetsky warned against “the tyranny of the continuous pulse oximeter.” He said pediatricians should use it in the office when deciding whether to hospitalize a patient; once the infant is admitted, however, he said to use it sparingly, especially in stable or improving patients.

“When you should give oxygen and when you should discharge, no one knows,” he said, adding that physicians should “avoid entrapment by data that has no clinical importance.”

Diarrhea Etiology Elusive

Stool testing turned up a bacterial pathogen in just 12 (5.3%) of 226 Seattle children enrolled in a prospective study of diarrhea in pediatric outpatient settings (Pediatr. Infect. Dis. J. 2005;24:142–8). Additional screening of smaller subgroups identified 1 child with a parasite, 8 with Clostridium difficile toxin, and 16 with viruses.

Donna M. Denno, M.D., of the University of Washington, Seattle, and her associates reported comparable results from two study sites: a private practice and a clinic in a municipal hospital serving a largely immigrant population.

The investigators associated bacterial infection with visible fecal blood, increased stool frequency, abdominal tenderness, and white or red cells in the stool. They noted, however, that 75% of children without a bacterial infection had at least one of these risk factors. Their conclusion: “Exclusion criteria for stool testing in diarrhea remain elusive.” Dr. Radetsky said that in most patients, conventional laboratory testing did not turn up a cause. His conclusion: “Stool cultures are infrequently needed in ambulatory practice.”

New Treatment for Head Lice

Dale Lawrence Pearlman, M.D., a dermatologist in Menlo Park, Calif., reported a 96% cure rate and 94% remission rate in two open clinical trials of a new treatment for head lice (Pediatrics 2004;114:e275–9).

Dr. Pearlman holds patents for Nuvo lotion, which he tested in 133 children recruited as being hard to treat. He declared Nuvo lotion to be the first in a new class of nontoxic lotions that he called dry-on, suffocation-based pediculides.

The report has drawn an accusation of hype (Lancet 2005;365:8–10), and the product has been likened to hair conditioner, according to Dr. Radetsky. Nonetheless, he held out hope that controlled trials could prove it to be “the up-and-coming treatment of choice.”

A new treatment is needed, he said. “Things are not going well for those of us that treat head lice. The success rate is going down. There are failures for head lice all over the place.”

A Bacterial Cause of Conjunctivitis?

Investigators from the University of Amsterdam in the Netherlands have come up with a scoring system for predicting a positive bacterial culture in a patient with conjunctivitis (BMJ 2004;329:206–10).

General practitioner Remco P. Rietveld, M.D., and his colleagues have proposed point values for glued eyes in the morning, itch, and history of conjunctivitis. Physicians use a patient's total points, based on a scale of −3 to +5, to calculate the probability of the patient testing positive. Though widely used, purulent secretion is almost diagnostically noninformative, the investigators said.

The cohort study was based on 184 adult patients enrolled from September 1999 to December 2002. Only about a third had a positive culture.

Dr. Radetsky said he included this article in his top 10 list because “there is no pediatric study that helps a practitioner to decide whether something is bacterial conjunctivitis or not.”

A similar study of children is needed, he said. Until one is done, this system enables physicians to reduce the use of topical antibiotics, based on the historical information provided.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Rabbie Hanna, M.D., and his colleagues reported the rate of successful labor induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

The researchers from Wayne State University in Detroit computed success rates of 71% for overweight women with a BMI range of 25–29 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 pregnancies that ended in elective cesarean section and 45,100 in which the women underwent labor (6,427 required induction).

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Rabbie Hanna, M.D., and his colleagues reported the rate of successful labor induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

The researchers from Wayne State University in Detroit computed success rates of 71% for overweight women with a BMI range of 25–29 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 pregnancies that ended in elective cesarean section and 45,100 in which the women underwent labor (6,427 required induction).

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Rabbie Hanna, M.D., and his colleagues reported the rate of successful labor induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

The researchers from Wayne State University in Detroit computed success rates of 71% for overweight women with a BMI range of 25–29 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 pregnancies that ended in elective cesarean section and 45,100 in which the women underwent labor (6,427 required induction).

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists. He reported maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that physicians may want to request stronger backup when operating on a woman who is older and overweight. “Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures. Other factors adding significantly to time in the operating room were a uterus incision other than a transverse incision, having a first year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose surgeries lasted longer than 60 minutes were nearly three times more likely to have their umbilical artery pH level below 7.1 and for their babies to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American; 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies. Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The only factors that shortened delivery time were maternal age less than 18 years and fetal distress.

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists. He reported maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that physicians may want to request stronger backup when operating on a woman who is older and overweight. “Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures. Other factors adding significantly to time in the operating room were a uterus incision other than a transverse incision, having a first year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose surgeries lasted longer than 60 minutes were nearly three times more likely to have their umbilical artery pH level below 7.1 and for their babies to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American; 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies. Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The only factors that shortened delivery time were maternal age less than 18 years and fetal distress.

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists. He reported maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that physicians may want to request stronger backup when operating on a woman who is older and overweight. “Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures. Other factors adding significantly to time in the operating room were a uterus incision other than a transverse incision, having a first year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose surgeries lasted longer than 60 minutes were nearly three times more likely to have their umbilical artery pH level below 7.1 and for their babies to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American; 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies. Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The only factors that shortened delivery time were maternal age less than 18 years and fetal distress.

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”

SANTA FE, N.M. — Pharmacotherapy does not cure autism, but it can make autistic children accessible to other modes of treatment, Bennett L. Leventhal, M.D., said at a psychiatric symposium sponsored by the University of Arizona.

“There are no pharmacological treatments for the cardinal symptoms of autism. Those things are not responsive to medication,” advised Dr. Leventhal, director of child and adolescent psychiatry at the University of Chicago. “But making kids available to other interventions may help them improve,” he said.

When children are referred for pharmacotherapy, it should begin with a complete work-up, he said. Though additional measures may be used, he said no child should be diagnosed without evaluation by two standard instruments: an Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS).

Dr. Leventhal recommended doing a physical examination with neurologic studies even if the child has been referred by a family physician.

Moreover, these children may have other impairments that were missed because of challenges in communicating with them.

For example, he said he has seen deaf children who were classified as autistic because no one recognized hearing loss.

Attention-deficit hyperactivity disorders used to be ruled out in autistic children, he said. While these youngsters can concentrate intensely on what interests them, specialists now recognize that many autistic children have difficulty paying attention.

Dr. Leventhal said he treats them with the same stimulants used for attention deficit in children who are not autistic. “There are no studies of stimulants in children with autism, but there is no reason to think these agents would not apply here,” he said.

No one stimulant has proved better than another, he added. The biggest problem, he said, is getting autistic children to swallow pills.

Dr. Leventhal recommended serotonin reuptake inhibitors (SSRIs) for control of stereotypic behaviors, such as repetitive behaviors, self-stimulatory behaviors (“stimming”), habits, and tics. He cited studies showing improvements with fluvoxamine (Arch. Gen. Psychiatry 1996; 53:1001–8) and fluoxetine (Neuropsychopharmacology 2005;30:582–9).

An added benefit is SSRIs can reduce aggression, he added, describing aggression and irritability as another serious problem for people with autism.

Dr. Leventhal reported that he no longer uses traditional neuroleptics because of side effects. Atypicals are coming into use, he said, but there is not much evidence in this population, except for risperidone (Risperdal).

Johnson & Johnson, parent company of risperidone maker Janssen Pharmaceutica Inc., announced in May that the Food and Drug Administration had informed the company that risperidone was “not approvable” for autism. Dr. Leventhal expressed bafflement at the decision, as he quoted data from studies that found risperidone to be effective (J. Am. Acad. Child Adolesc. Psychiatry 2002;41:140–7; Arch. Gen. Psychiatry 1998;55:633–41; N. Engl. J. Med. 2002;347:314–21).

“There's more than ample evidence that at least risperidone as an agent leads to better overall function and reduces irritability. The FDA did not think of much of the application. It looks like ample data to me,” said Dr. Leventhal, who listed a consulting relationship with Janssen in a disclosure of interests with several pharmaceutical companies.

The risperidone doses are “relatively modest”: 1–3 mg per day, he added, reporting better outcomes and fewer side effects with lower doses. Lithium is another option that reduces aggression regardless of diagnosis or cause, according to Dr. Leventhal, who said he has also used propranolol in extreme cases.

Whatever the agent, attention to dosing is critical, Dr. Leventhal said. “In children with autism, side effects are very difficult to treat and very difficult to follow because these kids are not verbal,” he said.

He discouraged use of novel anticonvulsants for mood disorders, anxiolytics for anxiety disorders, and chelation to remove heavy metals when treating autistic patients. Secretin, a drug that failed several randomized trials in autism, “may actually be harmful.”

The cognitive enhancers approved for Alzheimer's disease are a possibility for autism, he said. “Whether it works or not is an open question. Some of our data suggest this might have some utility.”

NICE, FRANCE — Now that safe and effective thrombolytic agents are available for short-term treatment of venous disease, Patrick Mismetti, M.D., has two questions he would like to see answered.

The first is how long to treat venous disease in high-risk patients. The second is, how can clinicians identify those high-risk patients who need long-term preventive therapy?

“We have to evaluate optimal duration of treatment, because there is a place between 6 months and indefinitely,” Dr. Mismetti said at the annual meeting of Cardiovascular and Interventional Radiological Society of Europe. He also called for an epidemiological study to identify patients at high risk of pulmonary embolism.

Physicians need to be able to individualize treatment, balancing the risk of disease recurrence against the risk of bleeding, according to Dr. Mismetti of the Thrombosis Research Group in Saint-Etienne, France.

“We have to try to identify patients at high risk of deep venous disease advancing in order to be aggressive in these patients and to use moderate treatment in other patients,” he said in an interview.

For short-term treatment, he told meeting attendees that low-molecular weight heparin or fondaparinux is preferred. Both are effective and as safe as unfractionated heparin in most patients. Although it is more difficult to administer, he said, unfractionated heparin should be used in patients at risk of major bleeding or severe renal insufficiency.

Long-term treatment reduced recurrences of venous disease in several studies cited by Dr. Mismetti. In one trial, comparing 1 month of therapy after a first episode with 3 months, the rate of recurrence at 1 year fell from 11.4% to 6.4% with the longer treatment (Thromb. Haemost. 1995:74:605–11).

In another study, comparing 1.5 months and 6 months of treatment, the recurrence rates at 2 years were 18.1% and 9.5%, respectively (N. Engl. J. Med. 1995:332:1661–5).

“In both cases, longer duration was associated with significant decrease in deep venous disease recurrences,” Dr. Mismetti said. “However, in certain circumstances, this short treatment of 3 months is not sufficient. We know people who need more treatment.”

For patients who have had a second episode, he cited a study comparing 6 months of treatment to indefinite therapy. Recurrences fell from 20.7% to 2.6% at 4 years with the longer treatment. Risk of major bleeding increased, however, from 2.7% to 8.6% (N. Engl. J. Med. 1997; 336:393–8).

Another placebo-controlled trial was stopped in patients with ideopathic venous disease, he added, because of the high rate of recurrence in patients who did not receive long-term treatment: 27.4% vs. 1.3% (N. Engl. J. Med. 1999;340:901–7).

Although 12 months is now recommended for some patients with idiopathic disease or a second episode, Dr. Mismetti questioned whether that was enough for those at high risk.

Use of a vena cava filter is another issue that needs further study, according to Dr. Mismetti. He was an investigator in the PREPIC (Prévention du Risque d'Embolie Pulmonaire par Interruption Cave) trial, which this summer reported filters reduced risk of pulmonary embolism but increased risk of deep venous thrombosis (Circulation 2005;112:416–22).

Studies are needed to identify the risk factors for recurrence of pulmonary embolism, he said, adding that the group hopes to start a second clinical trial next year.

Scott O. Trerotola, M.D., chair of the meeting session on venous disease, questioned why Dr. Mismetti did not support use of catheter-directed thrombolysis. Dr. Trerotola, of the University of Pennsylvania in Philadelphia, said a randomized study has shown “dramatic improvement” with the technique (Eur. J. Vasc. Endovasc. Surg. 2002;24:209–14).

“I have to present evidence-based medicine, and I try to do it,” Dr. Mismetti replied. “But we have some little experience with this technique, and the weight of deep venous disease recurrence is very high in our small clinical experience.”

“Clearly, for us in the DVT lysis community, the challenge is there to do these trials,” said Dr. Tretorola, noting that several clinical studies are underway.

In an interview, he added that a challenge to validating deep vein thrombolysis is that it works best in clots that are 7–10 days old. Given that many patients are now sent home with low-molecular weight heparin, he said, interventional radiologists often are not called until 2 and 3 weeks later in difficult cases.

“We used to have the opportunity to capture these patients while they were in the hospital and offer treatment for DVT,” he said. “Now we don't, because they're out.”

NICE, FRANCE — Now that safe and effective thrombolytic agents are available for short-term treatment of venous disease, Patrick Mismetti, M.D., has two questions he would like to see answered.

The first is how long to treat venous disease in high-risk patients. The second is, how can clinicians identify those high-risk patients who need long-term preventive therapy?

“We have to evaluate optimal duration of treatment, because there is a place between 6 months and indefinitely,” Dr. Mismetti said at the annual meeting of Cardiovascular and Interventional Radiological Society of Europe. He also called for an epidemiological study to identify patients at high risk of pulmonary embolism.

Physicians need to be able to individualize treatment, balancing the risk of disease recurrence against the risk of bleeding, according to Dr. Mismetti of the Thrombosis Research Group in Saint-Etienne, France.

“We have to try to identify patients at high risk of deep venous disease advancing in order to be aggressive in these patients and to use moderate treatment in other patients,” he said in an interview.

For short-term treatment, he told meeting attendees that low-molecular weight heparin or fondaparinux is preferred. Both are effective and as safe as unfractionated heparin in most patients. Although it is more difficult to administer, he said, unfractionated heparin should be used in patients at risk of major bleeding or severe renal insufficiency.

Long-term treatment reduced recurrences of venous disease in several studies cited by Dr. Mismetti. In one trial, comparing 1 month of therapy after a first episode with 3 months, the rate of recurrence at 1 year fell from 11.4% to 6.4% with the longer treatment (Thromb. Haemost. 1995:74:605–11).

In another study, comparing 1.5 months and 6 months of treatment, the recurrence rates at 2 years were 18.1% and 9.5%, respectively (N. Engl. J. Med. 1995:332:1661–5).

“In both cases, longer duration was associated with significant decrease in deep venous disease recurrences,” Dr. Mismetti said. “However, in certain circumstances, this short treatment of 3 months is not sufficient. We know people who need more treatment.”

For patients who have had a second episode, he cited a study comparing 6 months of treatment to indefinite therapy. Recurrences fell from 20.7% to 2.6% at 4 years with the longer treatment. Risk of major bleeding increased, however, from 2.7% to 8.6% (N. Engl. J. Med. 1997; 336:393–8).

Another placebo-controlled trial was stopped in patients with ideopathic venous disease, he added, because of the high rate of recurrence in patients who did not receive long-term treatment: 27.4% vs. 1.3% (N. Engl. J. Med. 1999;340:901–7).

Although 12 months is now recommended for some patients with idiopathic disease or a second episode, Dr. Mismetti questioned whether that was enough for those at high risk.

Use of a vena cava filter is another issue that needs further study, according to Dr. Mismetti. He was an investigator in the PREPIC (Prévention du Risque d'Embolie Pulmonaire par Interruption Cave) trial, which this summer reported filters reduced risk of pulmonary embolism but increased risk of deep venous thrombosis (Circulation 2005;112:416–22).

Studies are needed to identify the risk factors for recurrence of pulmonary embolism, he said, adding that the group hopes to start a second clinical trial next year.

Scott O. Trerotola, M.D., chair of the meeting session on venous disease, questioned why Dr. Mismetti did not support use of catheter-directed thrombolysis. Dr. Trerotola, of the University of Pennsylvania in Philadelphia, said a randomized study has shown “dramatic improvement” with the technique (Eur. J. Vasc. Endovasc. Surg. 2002;24:209–14).

“I have to present evidence-based medicine, and I try to do it,” Dr. Mismetti replied. “But we have some little experience with this technique, and the weight of deep venous disease recurrence is very high in our small clinical experience.”

“Clearly, for us in the DVT lysis community, the challenge is there to do these trials,” said Dr. Tretorola, noting that several clinical studies are underway.

In an interview, he added that a challenge to validating deep vein thrombolysis is that it works best in clots that are 7–10 days old. Given that many patients are now sent home with low-molecular weight heparin, he said, interventional radiologists often are not called until 2 and 3 weeks later in difficult cases.

“We used to have the opportunity to capture these patients while they were in the hospital and offer treatment for DVT,” he said. “Now we don't, because they're out.”

NICE, FRANCE — Now that safe and effective thrombolytic agents are available for short-term treatment of venous disease, Patrick Mismetti, M.D., has two questions he would like to see answered.

The first is how long to treat venous disease in high-risk patients. The second is, how can clinicians identify those high-risk patients who need long-term preventive therapy?

“We have to evaluate optimal duration of treatment, because there is a place between 6 months and indefinitely,” Dr. Mismetti said at the annual meeting of Cardiovascular and Interventional Radiological Society of Europe. He also called for an epidemiological study to identify patients at high risk of pulmonary embolism.

Physicians need to be able to individualize treatment, balancing the risk of disease recurrence against the risk of bleeding, according to Dr. Mismetti of the Thrombosis Research Group in Saint-Etienne, France.

“We have to try to identify patients at high risk of deep venous disease advancing in order to be aggressive in these patients and to use moderate treatment in other patients,” he said in an interview.

For short-term treatment, he told meeting attendees that low-molecular weight heparin or fondaparinux is preferred. Both are effective and as safe as unfractionated heparin in most patients. Although it is more difficult to administer, he said, unfractionated heparin should be used in patients at risk of major bleeding or severe renal insufficiency.

Long-term treatment reduced recurrences of venous disease in several studies cited by Dr. Mismetti. In one trial, comparing 1 month of therapy after a first episode with 3 months, the rate of recurrence at 1 year fell from 11.4% to 6.4% with the longer treatment (Thromb. Haemost. 1995:74:605–11).

In another study, comparing 1.5 months and 6 months of treatment, the recurrence rates at 2 years were 18.1% and 9.5%, respectively (N. Engl. J. Med. 1995:332:1661–5).

“In both cases, longer duration was associated with significant decrease in deep venous disease recurrences,” Dr. Mismetti said. “However, in certain circumstances, this short treatment of 3 months is not sufficient. We know people who need more treatment.”

For patients who have had a second episode, he cited a study comparing 6 months of treatment to indefinite therapy. Recurrences fell from 20.7% to 2.6% at 4 years with the longer treatment. Risk of major bleeding increased, however, from 2.7% to 8.6% (N. Engl. J. Med. 1997; 336:393–8).

Another placebo-controlled trial was stopped in patients with ideopathic venous disease, he added, because of the high rate of recurrence in patients who did not receive long-term treatment: 27.4% vs. 1.3% (N. Engl. J. Med. 1999;340:901–7).

Although 12 months is now recommended for some patients with idiopathic disease or a second episode, Dr. Mismetti questioned whether that was enough for those at high risk.

Use of a vena cava filter is another issue that needs further study, according to Dr. Mismetti. He was an investigator in the PREPIC (Prévention du Risque d'Embolie Pulmonaire par Interruption Cave) trial, which this summer reported filters reduced risk of pulmonary embolism but increased risk of deep venous thrombosis (Circulation 2005;112:416–22).

Studies are needed to identify the risk factors for recurrence of pulmonary embolism, he said, adding that the group hopes to start a second clinical trial next year.

Scott O. Trerotola, M.D., chair of the meeting session on venous disease, questioned why Dr. Mismetti did not support use of catheter-directed thrombolysis. Dr. Trerotola, of the University of Pennsylvania in Philadelphia, said a randomized study has shown “dramatic improvement” with the technique (Eur. J. Vasc. Endovasc. Surg. 2002;24:209–14).

“I have to present evidence-based medicine, and I try to do it,” Dr. Mismetti replied. “But we have some little experience with this technique, and the weight of deep venous disease recurrence is very high in our small clinical experience.”

“Clearly, for us in the DVT lysis community, the challenge is there to do these trials,” said Dr. Tretorola, noting that several clinical studies are underway.

In an interview, he added that a challenge to validating deep vein thrombolysis is that it works best in clots that are 7–10 days old. Given that many patients are now sent home with low-molecular weight heparin, he said, interventional radiologists often are not called until 2 and 3 weeks later in difficult cases.

“We used to have the opportunity to capture these patients while they were in the hospital and offer treatment for DVT,” he said. “Now we don't, because they're out.”

SCOTTSDALE, ARIZ. — Perineal repairs involving fast-absorbing polyglactin 910 sutures resulted in less pain and earlier resumption of sexual intercourse for new mothers in a randomized, controlled trial comparing the material with standard polyglactin 910 and chromic catgut.

Patients repaired with fast-absorbing polyglactin 910 sutures consumed fewer doses of analgesia and narcotics within 36–48 hours of giving birth. Two-thirds had resumed sexual intercourse at 6 weeks, and 48% had a pain-free experience, investigator Emmanuel Bujold, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Only 42% of women repaired with chromic catgut sutures and 56% with standard polyglactin 910 resumed intercourse at 6 weeks. Just 27% in the chromic catgut cohort and 42% in the standard polyglactin 910 group said intercourse was pain free.

“The benefits of fast-absorbing polyglactin 910 include less short-term perineal pain and probably a shorter time to resumption of pain-free sexual intercourse,” said Dr. Bujold of Ste. Justine Hospital and the University of Montreal.

Dr. Bujold and coinvestigator Nathalie Leroux, M.D., also of the University of Montreal, undertook the study to see if the fast-absorbing form of polyglactin 910 could offer the benefits of a synthetic suture without the problems associated with delayed absorption of sutures.

He described suture-related discomfort as very common, with 85% of women suffering some form of perineal trauma in spontaneous vaginal birth. Medical literature reports as many as 69% require sutures, according to the investigators. Most patients suffer perineal pain after delivery, and about a fifth have long-term problems.

The study enrolled women with uncomplicated pregnancies early in labor. Those who had an uncomplicated median episiotomy or a second-degree perineal tear were randomized to sutures made with the three materials: 66 to chromic catgut, 60 to standard polyglactin 910, and 66 to fast-absorbing polyglactin 910.

The well-balanced groups contained women 30 years old on average. More than half of the standard polyglactin 910 cohort and two-thirds of the other cohorts were nulliparous. More than 40% in each group required an episiotomy. About one in four had dyspareunia before pregnancy.

Investigators used a standard analgesia protocol: 50 mg of immediate-release indomethacin and 500 mg of naproxen every 12 hours for 24 hours. As-needed doses were standardized at 500 mg of naproxen every 12 hours, 30 mg of codeine plus 325 mg of acetaminophen, and 1 mg of hydromorphone.

Nurses doing postpartum pain assessments were blinded to the sutures used. Neither pain questionnaire nor visual analog scale scores showed significant differences in evaluation of perineal pain 36–48 hours after the women had given birth.

The median number of analgesic doses was seven with chromic catgut, eight with standard polyglactin 910, and six with fast-absorbing polyglactin 910. Narcotic doses averaged one with chromic catgut and two with standard polyglactin 910 but zero with fast-absorbing polyglactin 910.

At 6 weeks, the number of women for whom data were available had fallen to 53 of the women treated with chromic catgut, 43 with standard polyglactin 910, and 58 with fast-absorbing polyglactin 910.

The data on return to sexual intercourse and pain-free sexual intercourse were significant only when chromic catgut and fast-absorbing polyglactin 910 were compared. At 3 months postpartum, fast-absorbing polyglactin 910 still showed a slight advantage but it was not significant.

Stephen H. Cruikshank, M.D., of Wright State University in Dayton, Ohio, praised the investigators for “a simple but most effective study,” which received the association's Central Prize Award. Dr. Cruikshank, the association's new president, said, “It just goes to show us sometimes the most effective study is the simplest.”

SCOTTSDALE, ARIZ. — Perineal repairs involving fast-absorbing polyglactin 910 sutures resulted in less pain and earlier resumption of sexual intercourse for new mothers in a randomized, controlled trial comparing the material with standard polyglactin 910 and chromic catgut.

Patients repaired with fast-absorbing polyglactin 910 sutures consumed fewer doses of analgesia and narcotics within 36–48 hours of giving birth. Two-thirds had resumed sexual intercourse at 6 weeks, and 48% had a pain-free experience, investigator Emmanuel Bujold, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Only 42% of women repaired with chromic catgut sutures and 56% with standard polyglactin 910 resumed intercourse at 6 weeks. Just 27% in the chromic catgut cohort and 42% in the standard polyglactin 910 group said intercourse was pain free.

“The benefits of fast-absorbing polyglactin 910 include less short-term perineal pain and probably a shorter time to resumption of pain-free sexual intercourse,” said Dr. Bujold of Ste. Justine Hospital and the University of Montreal.

Dr. Bujold and coinvestigator Nathalie Leroux, M.D., also of the University of Montreal, undertook the study to see if the fast-absorbing form of polyglactin 910 could offer the benefits of a synthetic suture without the problems associated with delayed absorption of sutures.

He described suture-related discomfort as very common, with 85% of women suffering some form of perineal trauma in spontaneous vaginal birth. Medical literature reports as many as 69% require sutures, according to the investigators. Most patients suffer perineal pain after delivery, and about a fifth have long-term problems.

The study enrolled women with uncomplicated pregnancies early in labor. Those who had an uncomplicated median episiotomy or a second-degree perineal tear were randomized to sutures made with the three materials: 66 to chromic catgut, 60 to standard polyglactin 910, and 66 to fast-absorbing polyglactin 910.

The well-balanced groups contained women 30 years old on average. More than half of the standard polyglactin 910 cohort and two-thirds of the other cohorts were nulliparous. More than 40% in each group required an episiotomy. About one in four had dyspareunia before pregnancy.

Investigators used a standard analgesia protocol: 50 mg of immediate-release indomethacin and 500 mg of naproxen every 12 hours for 24 hours. As-needed doses were standardized at 500 mg of naproxen every 12 hours, 30 mg of codeine plus 325 mg of acetaminophen, and 1 mg of hydromorphone.

Nurses doing postpartum pain assessments were blinded to the sutures used. Neither pain questionnaire nor visual analog scale scores showed significant differences in evaluation of perineal pain 36–48 hours after the women had given birth.

The median number of analgesic doses was seven with chromic catgut, eight with standard polyglactin 910, and six with fast-absorbing polyglactin 910. Narcotic doses averaged one with chromic catgut and two with standard polyglactin 910 but zero with fast-absorbing polyglactin 910.

At 6 weeks, the number of women for whom data were available had fallen to 53 of the women treated with chromic catgut, 43 with standard polyglactin 910, and 58 with fast-absorbing polyglactin 910.

The data on return to sexual intercourse and pain-free sexual intercourse were significant only when chromic catgut and fast-absorbing polyglactin 910 were compared. At 3 months postpartum, fast-absorbing polyglactin 910 still showed a slight advantage but it was not significant.

Stephen H. Cruikshank, M.D., of Wright State University in Dayton, Ohio, praised the investigators for “a simple but most effective study,” which received the association's Central Prize Award. Dr. Cruikshank, the association's new president, said, “It just goes to show us sometimes the most effective study is the simplest.”

SCOTTSDALE, ARIZ. — Perineal repairs involving fast-absorbing polyglactin 910 sutures resulted in less pain and earlier resumption of sexual intercourse for new mothers in a randomized, controlled trial comparing the material with standard polyglactin 910 and chromic catgut.

Patients repaired with fast-absorbing polyglactin 910 sutures consumed fewer doses of analgesia and narcotics within 36–48 hours of giving birth. Two-thirds had resumed sexual intercourse at 6 weeks, and 48% had a pain-free experience, investigator Emmanuel Bujold, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Only 42% of women repaired with chromic catgut sutures and 56% with standard polyglactin 910 resumed intercourse at 6 weeks. Just 27% in the chromic catgut cohort and 42% in the standard polyglactin 910 group said intercourse was pain free.

“The benefits of fast-absorbing polyglactin 910 include less short-term perineal pain and probably a shorter time to resumption of pain-free sexual intercourse,” said Dr. Bujold of Ste. Justine Hospital and the University of Montreal.

Dr. Bujold and coinvestigator Nathalie Leroux, M.D., also of the University of Montreal, undertook the study to see if the fast-absorbing form of polyglactin 910 could offer the benefits of a synthetic suture without the problems associated with delayed absorption of sutures.

He described suture-related discomfort as very common, with 85% of women suffering some form of perineal trauma in spontaneous vaginal birth. Medical literature reports as many as 69% require sutures, according to the investigators. Most patients suffer perineal pain after delivery, and about a fifth have long-term problems.

The study enrolled women with uncomplicated pregnancies early in labor. Those who had an uncomplicated median episiotomy or a second-degree perineal tear were randomized to sutures made with the three materials: 66 to chromic catgut, 60 to standard polyglactin 910, and 66 to fast-absorbing polyglactin 910.

The well-balanced groups contained women 30 years old on average. More than half of the standard polyglactin 910 cohort and two-thirds of the other cohorts were nulliparous. More than 40% in each group required an episiotomy. About one in four had dyspareunia before pregnancy.

Investigators used a standard analgesia protocol: 50 mg of immediate-release indomethacin and 500 mg of naproxen every 12 hours for 24 hours. As-needed doses were standardized at 500 mg of naproxen every 12 hours, 30 mg of codeine plus 325 mg of acetaminophen, and 1 mg of hydromorphone.

Nurses doing postpartum pain assessments were blinded to the sutures used. Neither pain questionnaire nor visual analog scale scores showed significant differences in evaluation of perineal pain 36–48 hours after the women had given birth.

The median number of analgesic doses was seven with chromic catgut, eight with standard polyglactin 910, and six with fast-absorbing polyglactin 910. Narcotic doses averaged one with chromic catgut and two with standard polyglactin 910 but zero with fast-absorbing polyglactin 910.

At 6 weeks, the number of women for whom data were available had fallen to 53 of the women treated with chromic catgut, 43 with standard polyglactin 910, and 58 with fast-absorbing polyglactin 910.

The data on return to sexual intercourse and pain-free sexual intercourse were significant only when chromic catgut and fast-absorbing polyglactin 910 were compared. At 3 months postpartum, fast-absorbing polyglactin 910 still showed a slight advantage but it was not significant.

Stephen H. Cruikshank, M.D., of Wright State University in Dayton, Ohio, praised the investigators for “a simple but most effective study,” which received the association's Central Prize Award. Dr. Cruikshank, the association's new president, said, “It just goes to show us sometimes the most effective study is the simplest.”