Jane Salodof MacNeil

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

SANTA FE, N.M.–Clinical depression is common in cancer patients and can affect outcomes of cancer therapy if not treated.

About 13% of cancer patients develop a major depressive disorder within 2 years of diagnosis, Karen Weihs, M.D., said at a psychiatric symposium sponsored by the University of Arizona. Some cancers have much higher rates, according to Dr. Weihs, a psychiatrist at the university, in Tucson.

“Depression really is an overrepresented phenomenon, even compared to other kinds of illness,” she said, describing the likelihood of depression as more than twice the experience in patients diagnosed with heart disease (Arch. Intern. Med. 2005;165:1260–6).

A recent monograph reported depression to be most prevalent in patients with oropharyngeal (22%–57%), pancreatic (33%–50%), breast (1%–46%), and lung (11%–44%) cancers (J. Natl. Cancer Inst. Monogr. 2004;32:57–71). Depression was also common for patients with colon cancer (13%–25%), gynecological cancer (12%–23%), and lymphoma (9%–19%).

Depressed breast cancer patients have higher mortality than those who are not treated, according to Dr. Weihs. One study put their relative risk at 1.42 (J. Am. Geriatr. Soc. 2004;52:106–11).

Often depression is accompanied by symptoms of post-traumatic stress disorder, though not the full syndrome, she added. About 75% of depressed breast cancer patients will have intrusive memories 19 months after diagnosis.

Along with cancer type, she cited disease severity (threat of early death), pain, declining physical status, and the effects of cancer treatment as general risk factors for depression. Changing from caregiver to care receiver can cause distress, she said, and patients with a history of depression are vulnerable.

Physical and psychological symptoms are more common with chemotherapy, according to Dr. Weihs. One study found clinical depression in 28% of women who underwent chemotherapy and mastectomy but only 17% of women who had mastectomy without chemotherapy (J. Natl. Cancer Inst. 2004;96;376–87).

Cytokines probably play a role in cancer-related depression, she said, noting that pancreatic tumors are characterized by high cytokine release. Depressed cancer patients have elevated cytokines compared with cancer patients who are not depressed, she added.

Some cancer drugs may promote depression. Dr. Weihs noted that procarbazine inhibits dopamine beta-hydroxylase, while vincristine and vinblastine decrease conversion of dopamine to norepinephrine.

In addition, higher depression rates have been reported in women on tamoxifen: 15%, versus 3% in a control group (Breast Cancer Res. Treat. 1993;27:277–81).

Interferon-α, used to treat malignant melanoma and renal cell cancer, has been linked to major depressive disorder in 21%–58% of patients, she added. Increasing dosage and duration increases risk.

Most of what is known about depression and cancer comes from breast cancer studies, according to Dr. Weihs. While most enrolled well-educated white women, she noted that high point prevalence of depression has also been found in low-income, Hispanic women (J. Clin. Oncol. 2005;23:3052–60).

Distinguishing clinical depression from grief over a cancer diagnosis is challenging, especially in patients with a terminal prognosis. “For people who don't see a lot of cancer patients, it is hard to know what is disproportionate,” said Dr. Weihs.

She recommended approaching cancer patients on a mental health continuum. Many will function well at diagnosis, she said, and some who react poorly improve over time. About 12% deteriorate and need intervention. Accordingly, Dr. Weihs suggested staging depression in cancer patients as follows:

▸ Prior history that recurs with the cancer.

▸ First episode occurs during acute treatment for cancer.

▸ Related to medication or a medical complication.

▸ Starts after acute treatment in survivorship phase.

Few studies have tested antidepressants in cancer patients, but Dr. Weihs said the results were consistent: Treatment reduces depression scores on standard measures. One caveat is that paroxetine (Paxil) should not be given to patients who are taking tamoxifen, as it may inhibit the drug's activity.

She also recommended psychosocial interventions, including education, behavioral therapy, and individual and group psychotherapy for cancer-related distress. Psychostimulants should be reserved for patients with short life expectancy, as tolerance is not a risk and rapid action is needed, Dr. Weihs said.

Findings from the Corticosteroid Randomization After Significant Head Injury (CRASH) trial that intravenous corticosteroids increased mortality among patients with traumatic brain injury should put to rest once and for all questions about the role of steroids for this indication, Donald Marion, M.D., told this newspaper.

Current guidelines on the management and prognosis of severe head injury do not recommend use of intravenous corticosteroids, said Dr. Marion, a Boston-based senior research fellow at the Brain Trauma Foundation, New York.

Intravenous steroid use for this indication has been on the decline for at least 10 years in the United States. A decade ago, 60%–70% of physicians used steroids in the treatment of traumatic brain injury (TBI); today that has dropped to about 20%.

Negative findings from the unusually large British CRASH trial of more than 10,000 patients should end debate over use of corticosteroids after head injuries, according to Dr. Marion.

Investigators in the United Kingdom randomized 10,008 adult TBI patients to a 48-hour infusion of methylprednisolone or placebo. They reported 25.7% of the corticosteroid group but only 22.3% of the placebo group died within 6 months of entering the CRASH trial.

Although fewer patients developed severe disability on corticosteroids, the combined outcome of death or severe disability still favored the placebo. In the corticosteroid arm, 38.1% were dead or severely disabled at 6 months, compared with 36.3% of the control group (Lancet 2005;365:1957–9).

“These analyses lend support to the conclusion … that corticosteroids should not routinely be used in the treatment of head injury,” the CRASH trial collaborators stated in a research letter.

The results provide “clear evidence that treatment with corticosteroids following head injury affords no material benefit,” according to the investigators.

“The absence of evidence of any neurologic benefit from corticosteroid treatment might also have implications for the use of corticosteroids in spinal cord injury, which should remain an area for debate.”

The trial randomized patients with a Glasgow Coma Scale score of 14 or less within 8 hours of head injury. All patients received a 48-hour infusion of either placebo or methylprednisolone, which Pfizer provided.

The 6-month analysis was based on follow-up data for 9,673 patients (96.7%): 4,854 on corticosteroids and 4,819 patients on placebo.

At that point, a total of 1,248 corticosteroid patients and 1,075 placebo patients had died.

Conversely, 2,213 placebo patients (45.9%), but only 2,120 corticosteroid patients (43.7%), had made a good recovery. Stratification by severity of head injury and time from injury produced no substantial differences.

Dr. Marion noted in his interview with this newspaper that “the question they [the CRASH researchers] really needed to answer was not whether steroids were bad, but whether steroids improve outcome.

“They not only proved steroids did not improve outcome but also that people who had steroids had worse outcomes. … Those people who are following evidence-based medicine are not likely to use steroids.”

Findings from the Corticosteroid Randomization After Significant Head Injury (CRASH) trial that intravenous corticosteroids increased mortality among patients with traumatic brain injury should put to rest once and for all questions about the role of steroids for this indication, Donald Marion, M.D., told this newspaper.

Current guidelines on the management and prognosis of severe head injury do not recommend use of intravenous corticosteroids, said Dr. Marion, a Boston-based senior research fellow at the Brain Trauma Foundation, New York.

Intravenous steroid use for this indication has been on the decline for at least 10 years in the United States. A decade ago, 60%–70% of physicians used steroids in the treatment of traumatic brain injury (TBI); today that has dropped to about 20%.

Negative findings from the unusually large British CRASH trial of more than 10,000 patients should end debate over use of corticosteroids after head injuries, according to Dr. Marion.

Investigators in the United Kingdom randomized 10,008 adult TBI patients to a 48-hour infusion of methylprednisolone or placebo. They reported 25.7% of the corticosteroid group but only 22.3% of the placebo group died within 6 months of entering the CRASH trial.

Although fewer patients developed severe disability on corticosteroids, the combined outcome of death or severe disability still favored the placebo. In the corticosteroid arm, 38.1% were dead or severely disabled at 6 months, compared with 36.3% of the control group (Lancet 2005;365:1957–9).

“These analyses lend support to the conclusion … that corticosteroids should not routinely be used in the treatment of head injury,” the CRASH trial collaborators stated in a research letter.

The results provide “clear evidence that treatment with corticosteroids following head injury affords no material benefit,” according to the investigators.

“The absence of evidence of any neurologic benefit from corticosteroid treatment might also have implications for the use of corticosteroids in spinal cord injury, which should remain an area for debate.”

The trial randomized patients with a Glasgow Coma Scale score of 14 or less within 8 hours of head injury. All patients received a 48-hour infusion of either placebo or methylprednisolone, which Pfizer provided.

The 6-month analysis was based on follow-up data for 9,673 patients (96.7%): 4,854 on corticosteroids and 4,819 patients on placebo.

At that point, a total of 1,248 corticosteroid patients and 1,075 placebo patients had died.

Conversely, 2,213 placebo patients (45.9%), but only 2,120 corticosteroid patients (43.7%), had made a good recovery. Stratification by severity of head injury and time from injury produced no substantial differences.

Dr. Marion noted in his interview with this newspaper that “the question they [the CRASH researchers] really needed to answer was not whether steroids were bad, but whether steroids improve outcome.

“They not only proved steroids did not improve outcome but also that people who had steroids had worse outcomes. … Those people who are following evidence-based medicine are not likely to use steroids.”

Findings from the Corticosteroid Randomization After Significant Head Injury (CRASH) trial that intravenous corticosteroids increased mortality among patients with traumatic brain injury should put to rest once and for all questions about the role of steroids for this indication, Donald Marion, M.D., told this newspaper.

Current guidelines on the management and prognosis of severe head injury do not recommend use of intravenous corticosteroids, said Dr. Marion, a Boston-based senior research fellow at the Brain Trauma Foundation, New York.

Intravenous steroid use for this indication has been on the decline for at least 10 years in the United States. A decade ago, 60%–70% of physicians used steroids in the treatment of traumatic brain injury (TBI); today that has dropped to about 20%.

Negative findings from the unusually large British CRASH trial of more than 10,000 patients should end debate over use of corticosteroids after head injuries, according to Dr. Marion.

Investigators in the United Kingdom randomized 10,008 adult TBI patients to a 48-hour infusion of methylprednisolone or placebo. They reported 25.7% of the corticosteroid group but only 22.3% of the placebo group died within 6 months of entering the CRASH trial.

Although fewer patients developed severe disability on corticosteroids, the combined outcome of death or severe disability still favored the placebo. In the corticosteroid arm, 38.1% were dead or severely disabled at 6 months, compared with 36.3% of the control group (Lancet 2005;365:1957–9).

“These analyses lend support to the conclusion … that corticosteroids should not routinely be used in the treatment of head injury,” the CRASH trial collaborators stated in a research letter.

The results provide “clear evidence that treatment with corticosteroids following head injury affords no material benefit,” according to the investigators.

“The absence of evidence of any neurologic benefit from corticosteroid treatment might also have implications for the use of corticosteroids in spinal cord injury, which should remain an area for debate.”

The trial randomized patients with a Glasgow Coma Scale score of 14 or less within 8 hours of head injury. All patients received a 48-hour infusion of either placebo or methylprednisolone, which Pfizer provided.

The 6-month analysis was based on follow-up data for 9,673 patients (96.7%): 4,854 on corticosteroids and 4,819 patients on placebo.

At that point, a total of 1,248 corticosteroid patients and 1,075 placebo patients had died.

Conversely, 2,213 placebo patients (45.9%), but only 2,120 corticosteroid patients (43.7%), had made a good recovery. Stratification by severity of head injury and time from injury produced no substantial differences.

Dr. Marion noted in his interview with this newspaper that “the question they [the CRASH researchers] really needed to answer was not whether steroids were bad, but whether steroids improve outcome.

“They not only proved steroids did not improve outcome but also that people who had steroids had worse outcomes. … Those people who are following evidence-based medicine are not likely to use steroids.”

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”

ORLANDO — Toremifene citrate, an estrogen blocker approved for the treatment of advanced breast cancer, significantly reduced the incidence of prostate cancer in high-risk patients enrolled in a double-blind, randomized, phase IIb trial.

Investigator David Price, M.D., reported a 48% reduction in prostate cancer risk for high-grade prostatic intraepithelial neoplasia (PIN) patients who took 20 mg of toremifene each day for a full year. Prostate cancer was diagnosed over the course of the 12-month trial in 31.2% of patients in a placebo group, and 24.4% of those on the 20-mg dose.

Cohorts that completed a year of therapy at higher doses of toremifene also showed lower incidence of cancer, but the differences compared with placebo were not statistically significant. The proportion of 12-month biopsies showing prostate cancer was 9% of 88 men still taking 20 mg of toremifene, 14.3% of 91 men taking 40 mg, and 13% of 77 men treated with 60 mg. The highest cancer rate, 17%, was found among 86 men still taking placebo.

Dr. Price, director of urologic oncology and clinical research at Regional Urology, LLC, in Shreveport, La., presented data at the American Society of Clinical Oncology's annual meeting. He identified himself as a consultant to GTx Inc. in Memphis, which sponsored the trial. The company sells the drug, a selective estrogen receptor modulator, under the brand name Fareston for breast cancer and is developing it for prostate cancer under the name Acapodene.

The study enrolled 514 PIN patients at 64 sites across the United States. Researchers randomized 130 men to placebo, 125 to 20 mg of toremifene, 134 to 40 mg, and 125 to 60 mg. Age and prostate-specific antigen levels were similar across the cohorts.

At 6 months, rates of prostate cancer diagnoses were comparable for the 20-mg and placebo groups: 15.7% and 15.9%, respectively. Dr. Price said he believed the 6-month biopsies detected cancers missed at baseline. Consequently, he proposed that the 12-month biopsy data are more reflective of toremifene's effectiveness.

PIN patients are at substantially higher risk for prostate cancer than are men with high prostate-specific antigen levels, according to Dr. Price. He described PIN as a precancerous condition, comparable with colon polyps, in which abnormal cells are moving toward a malignant state.

“Right now we do not recommend any aggressive treatment for PIN,” he said at a press briefing, describing an anxiety-generating watch-and-wait strategy with repeated biopsies as the only option.

“This study documents the natural history of PIN,” he added, noting that prior estimates of cancer progression were based on retrospective data. “For the first time in a large prospective fashion, we demonstrated that these patients are truly at risk—that one in three is going to develop prostate cancer [within a year].”

Toremifene was well tolerated, with comparable proportions of patients on the drug (7%–9%) and the placebo (11%) reporting at least one serious adverse event. Its most common side effect, fatigue, occurred in 5% of the group taking 20 mg, the most effective dose, according to the presentation.

Gleason scores in men who developed prostate cancer were slightly lower (6.1%) in the 20-mg group than in the placebo group (7.4%). Dr. Price interpreted this as evidence that chemoprevention did not make cancers worse than they would have been without the trial.

The preventive effect demonstrated so far is 10-fold greater than that of tamoxifen against breast cancer, according to Dr. Price. Based on the phase IIb data, he estimated daily toremifene use could prevent 6.8 prostate cancers per 100 patients treated per year. He contrasted this with the National Surgical Adjuvant Breast and Bowel Project B-24 trial, in which tamoxifen use prevented 0.71 cancers per 100 patients with ductal carcinoma in situ after 1 year of treatment.

Audience members challenged him to state the actual numbers, and not just percentages, of patients who developed prostate cancer in the trial. He said 16 patients were diagnosed in the placebo group and 12 in the 20-mg cohort.

In a discussion of the trial, Otis W. Brawley, M.D, associate director of the Winship Cancer Institute at Emory University in Atlanta, noted that the absolute difference was only four fewer men developing prostate cancer: “A reduction of four—total.”

ORLANDO — Toremifene citrate, an estrogen blocker approved for the treatment of advanced breast cancer, significantly reduced the incidence of prostate cancer in high-risk patients enrolled in a double-blind, randomized, phase IIb trial.

Investigator David Price, M.D., reported a 48% reduction in prostate cancer risk for high-grade prostatic intraepithelial neoplasia (PIN) patients who took 20 mg of toremifene each day for a full year. Prostate cancer was diagnosed over the course of the 12-month trial in 31.2% of patients in a placebo group, and 24.4% of those on the 20-mg dose.

Cohorts that completed a year of therapy at higher doses of toremifene also showed lower incidence of cancer, but the differences compared with placebo were not statistically significant. The proportion of 12-month biopsies showing prostate cancer was 9% of 88 men still taking 20 mg of toremifene, 14.3% of 91 men taking 40 mg, and 13% of 77 men treated with 60 mg. The highest cancer rate, 17%, was found among 86 men still taking placebo.

Dr. Price, director of urologic oncology and clinical research at Regional Urology, LLC, in Shreveport, La., presented data at the American Society of Clinical Oncology's annual meeting. He identified himself as a consultant to GTx Inc. in Memphis, which sponsored the trial. The company sells the drug, a selective estrogen receptor modulator, under the brand name Fareston for breast cancer and is developing it for prostate cancer under the name Acapodene.

The study enrolled 514 PIN patients at 64 sites across the United States. Researchers randomized 130 men to placebo, 125 to 20 mg of toremifene, 134 to 40 mg, and 125 to 60 mg. Age and prostate-specific antigen levels were similar across the cohorts.

At 6 months, rates of prostate cancer diagnoses were comparable for the 20-mg and placebo groups: 15.7% and 15.9%, respectively. Dr. Price said he believed the 6-month biopsies detected cancers missed at baseline. Consequently, he proposed that the 12-month biopsy data are more reflective of toremifene's effectiveness.

PIN patients are at substantially higher risk for prostate cancer than are men with high prostate-specific antigen levels, according to Dr. Price. He described PIN as a precancerous condition, comparable with colon polyps, in which abnormal cells are moving toward a malignant state.

“Right now we do not recommend any aggressive treatment for PIN,” he said at a press briefing, describing an anxiety-generating watch-and-wait strategy with repeated biopsies as the only option.

“This study documents the natural history of PIN,” he added, noting that prior estimates of cancer progression were based on retrospective data. “For the first time in a large prospective fashion, we demonstrated that these patients are truly at risk—that one in three is going to develop prostate cancer [within a year].”

Toremifene was well tolerated, with comparable proportions of patients on the drug (7%–9%) and the placebo (11%) reporting at least one serious adverse event. Its most common side effect, fatigue, occurred in 5% of the group taking 20 mg, the most effective dose, according to the presentation.

Gleason scores in men who developed prostate cancer were slightly lower (6.1%) in the 20-mg group than in the placebo group (7.4%). Dr. Price interpreted this as evidence that chemoprevention did not make cancers worse than they would have been without the trial.

The preventive effect demonstrated so far is 10-fold greater than that of tamoxifen against breast cancer, according to Dr. Price. Based on the phase IIb data, he estimated daily toremifene use could prevent 6.8 prostate cancers per 100 patients treated per year. He contrasted this with the National Surgical Adjuvant Breast and Bowel Project B-24 trial, in which tamoxifen use prevented 0.71 cancers per 100 patients with ductal carcinoma in situ after 1 year of treatment.

Audience members challenged him to state the actual numbers, and not just percentages, of patients who developed prostate cancer in the trial. He said 16 patients were diagnosed in the placebo group and 12 in the 20-mg cohort.

In a discussion of the trial, Otis W. Brawley, M.D, associate director of the Winship Cancer Institute at Emory University in Atlanta, noted that the absolute difference was only four fewer men developing prostate cancer: “A reduction of four—total.”

ORLANDO — Toremifene citrate, an estrogen blocker approved for the treatment of advanced breast cancer, significantly reduced the incidence of prostate cancer in high-risk patients enrolled in a double-blind, randomized, phase IIb trial.

Investigator David Price, M.D., reported a 48% reduction in prostate cancer risk for high-grade prostatic intraepithelial neoplasia (PIN) patients who took 20 mg of toremifene each day for a full year. Prostate cancer was diagnosed over the course of the 12-month trial in 31.2% of patients in a placebo group, and 24.4% of those on the 20-mg dose.

Cohorts that completed a year of therapy at higher doses of toremifene also showed lower incidence of cancer, but the differences compared with placebo were not statistically significant. The proportion of 12-month biopsies showing prostate cancer was 9% of 88 men still taking 20 mg of toremifene, 14.3% of 91 men taking 40 mg, and 13% of 77 men treated with 60 mg. The highest cancer rate, 17%, was found among 86 men still taking placebo.

Dr. Price, director of urologic oncology and clinical research at Regional Urology, LLC, in Shreveport, La., presented data at the American Society of Clinical Oncology's annual meeting. He identified himself as a consultant to GTx Inc. in Memphis, which sponsored the trial. The company sells the drug, a selective estrogen receptor modulator, under the brand name Fareston for breast cancer and is developing it for prostate cancer under the name Acapodene.

The study enrolled 514 PIN patients at 64 sites across the United States. Researchers randomized 130 men to placebo, 125 to 20 mg of toremifene, 134 to 40 mg, and 125 to 60 mg. Age and prostate-specific antigen levels were similar across the cohorts.

At 6 months, rates of prostate cancer diagnoses were comparable for the 20-mg and placebo groups: 15.7% and 15.9%, respectively. Dr. Price said he believed the 6-month biopsies detected cancers missed at baseline. Consequently, he proposed that the 12-month biopsy data are more reflective of toremifene's effectiveness.

PIN patients are at substantially higher risk for prostate cancer than are men with high prostate-specific antigen levels, according to Dr. Price. He described PIN as a precancerous condition, comparable with colon polyps, in which abnormal cells are moving toward a malignant state.

“Right now we do not recommend any aggressive treatment for PIN,” he said at a press briefing, describing an anxiety-generating watch-and-wait strategy with repeated biopsies as the only option.

“This study documents the natural history of PIN,” he added, noting that prior estimates of cancer progression were based on retrospective data. “For the first time in a large prospective fashion, we demonstrated that these patients are truly at risk—that one in three is going to develop prostate cancer [within a year].”

Toremifene was well tolerated, with comparable proportions of patients on the drug (7%–9%) and the placebo (11%) reporting at least one serious adverse event. Its most common side effect, fatigue, occurred in 5% of the group taking 20 mg, the most effective dose, according to the presentation.

Gleason scores in men who developed prostate cancer were slightly lower (6.1%) in the 20-mg group than in the placebo group (7.4%). Dr. Price interpreted this as evidence that chemoprevention did not make cancers worse than they would have been without the trial.

The preventive effect demonstrated so far is 10-fold greater than that of tamoxifen against breast cancer, according to Dr. Price. Based on the phase IIb data, he estimated daily toremifene use could prevent 6.8 prostate cancers per 100 patients treated per year. He contrasted this with the National Surgical Adjuvant Breast and Bowel Project B-24 trial, in which tamoxifen use prevented 0.71 cancers per 100 patients with ductal carcinoma in situ after 1 year of treatment.

Audience members challenged him to state the actual numbers, and not just percentages, of patients who developed prostate cancer in the trial. He said 16 patients were diagnosed in the placebo group and 12 in the 20-mg cohort.

In a discussion of the trial, Otis W. Brawley, M.D, associate director of the Winship Cancer Institute at Emory University in Atlanta, noted that the absolute difference was only four fewer men developing prostate cancer: “A reduction of four—total.”

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Diya I. Alaedeen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 g, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen.

“It is likely that our babies were overfed. When [infants] are ill, they are not using these calories to grow,” he added in an interview.

Dr. Alaedeen noted that the project could not discern to what degree hyperglycemia was a result of overfeeding by total parenteral nutrition as distinguished from a response to injury. To resolve that issue, he called for a prospective study “correlating C-reactive protein, as a measure of acute metabolic stress, and/or MEE [measured energy expenditure] with caloric delivery.”

Moderator Daniel H. Teitelbaum, M.D., of the University of Michigan in Ann Arbor, praised the presentation as “a wonderful study.” He noted that it echoes correlations in an influential paper associating hyperglycemia with worse outcomes in critically ill adults (N. Engl. J. Med. 2001; 345:1359–67).

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Diya I. Alaedeen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 g, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen.

“It is likely that our babies were overfed. When [infants] are ill, they are not using these calories to grow,” he added in an interview.

Dr. Alaedeen noted that the project could not discern to what degree hyperglycemia was a result of overfeeding by total parenteral nutrition as distinguished from a response to injury. To resolve that issue, he called for a prospective study “correlating C-reactive protein, as a measure of acute metabolic stress, and/or MEE [measured energy expenditure] with caloric delivery.”

Moderator Daniel H. Teitelbaum, M.D., of the University of Michigan in Ann Arbor, praised the presentation as “a wonderful study.” He noted that it echoes correlations in an influential paper associating hyperglycemia with worse outcomes in critically ill adults (N. Engl. J. Med. 2001; 345:1359–67).

PHOENIX — Critically ill infants on total parenteral nutrition may face more complications and worse outcomes as a result of hyperglycemia induced by overfeeding, reported Diya I. Alaedeen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A retrospective review of 37 premature infants treated for sepsis during a 1-year period found associations between hyperglycemia, morbidity, and mortality. The higher their maximum serum glucose concentration, the longer the babies were on mechanical ventilation and the longer they stayed in the hospital, Dr. Alaedeen said.

The average maximum glucose level was 100 mg/dL higher in 6 babies (16%) who died than in 31 babies who lived. It reached 241 mg/dL in nonsurvivors vs. 141 mg/dL in survivors.

“Avoiding caloric overfeeding, perhaps with tight glycemic control, in critically ill infants might be effective for reducing hyperglycemia-associated morbidity and mortality,” said Dr. Alaedeen of Rainbow Babies and Children's Hospital in Cleveland.

Dr. Alaedeen and his colleagues reviewed all ventilator-dependent premature infants who weighed less than 1,500 g, had culture-proven sepsis, and required total parenteral nutrition while treated in the hospital's neonatal intensive care unit during 2002. Coagulase-negative staphylococci were the most common cause of sepsis, identified in 76% of cases.

Among survivors, 20 infants had maximum glucose levels above 120 mg/dL; their average length of stay exceeded 100 days. The other 11 survivors had levels at or below 120 mg/dL and stayed a little more than 60 days on average.

The study found that the average caloric intake for all infants was 83 ±19 kcal/kg per day during the first week after sepsis was proved by culture. This intake exceeds the average measured energy expenditure of 40–60 kcal/kg per day observed in infants during states of acute metabolic stress, according to Dr. Alaedeen.

“It is likely that our babies were overfed. When [infants] are ill, they are not using these calories to grow,” he added in an interview.

Dr. Alaedeen noted that the project could not discern to what degree hyperglycemia was a result of overfeeding by total parenteral nutrition as distinguished from a response to injury. To resolve that issue, he called for a prospective study “correlating C-reactive protein, as a measure of acute metabolic stress, and/or MEE [measured energy expenditure] with caloric delivery.”

Moderator Daniel H. Teitelbaum, M.D., of the University of Michigan in Ann Arbor, praised the presentation as “a wonderful study.” He noted that it echoes correlations in an influential paper associating hyperglycemia with worse outcomes in critically ill adults (N. Engl. J. Med. 2001; 345:1359–67).

PHOENIX — Benefits and complications resulting from Roux-en-Y gastric bypass procedures are similar for both adolescents and adults, according to data presented by Mike K. Chen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A multicenter review of 37 adolescents who underwent the procedure showed that average body mass index decreased by 20.7 kg/m

“While there are considerable risks with bariatric surgery, early experience suggests that these risks are offset by health benefits in these patients,” Dr. Chen said.

Five surgeons performed the operations on adolescents aged 13–21 years at three pediatric centers: Dr. Chen's institution, Children's Hospital of Alabama (University of Alabama, Birmingham), and Cincinnati Children's Hospital Medical Center (University of Cincinnati).

In 36 cases, the surgeons attempted laparoscopic procedures. Two were converted to open procedures, however, bringing to three the number of open procedures in the sample. Roux limb lengths were reported as 75–150 cm, and gastric pouch size as 30–45 cc.

Average body mass index at baseline was 56.5 kg/m

Dr. Chen itemized the metabolic data as follows: fasting insulin decreased by 21.3 μU/mL in 14 patients, fasting glucose by 12 g/dL in 10 patients, homeostasis model assessment-insulin resistance (HOMA-IR) by 4.6 in 9 patients, triglycerides by 65.1 mg/dL in 17 patients, and total cholesterol by 29.7 mg/dL in 18 patients.

Because of the small sample size, Dr. Chen and his coauthors did not calculate rates for individual complications but reported adverse events in categories.

They classified a complication as minor if the patient was readmitted to the hospital for less than 7 days of treatment, which could be endoscopy or diagnostic studies. Nine adolescents had minor complications, identified as endoscopy, food obstruction, wound infection, stricture, dumping syndrome secondary to overeating, mild beriberi that responded to outpatient treatment, hypokalemia, and deep vein thrombosis.

The investigators defined a moderate complication as unanticipated admission to an intensive care unit, reoperation, or sequelae lasting 7–30 days. Four patients had moderate complications. Dr. Chen listed these as persistent iron deficiency anemia, peripheral neuropathy secondary to vitamin deficiency, reoperation, shock, or internal hernia. He said the reasons for reoperation were staple line leak, obstruction, and gastrostomy revision.

A severe complication could be a life-threatening event, a major organ system failure, or sequelae lasting more than 30 days. Only two patients had a severe complication: a teenager who died 9 months after surgery from colitis that developed during rehabilitation for osteoarthritis, and one who experienced beriberi with sequelae for 2 months. The rest of the complications were mild to moderate, and 22 patients (61%) had none at all.

Dr. Chen said the surgeons undertook the analysis in response to a call for outcome studies in recently published guidelines for bariatric surgery in patients between the ages of 13 and 21 (Pediatrics 2004;114:217–23).

He cited one previous report of efficacy and complication rates, noting it was limited to 33 adolescents treated over 20 years at a single adult institution (J. Gastrointest. Surg. 2003;7:102–7).

“The vast majority of patients who undergo bariatric surgery are adults in their fifth decade of life,” Dr. Chen said, adding that outcome data clearly support the procedure's efficacy in the older population.

About 15.5% of adolescents are overweight, he said, adding that “50%–75% of these obese kids become obese adults.” Without a successful intervention, he warned, the consequences can include physical and psychosocial conditions and lost years of life.

PHOENIX — Benefits and complications resulting from Roux-en-Y gastric bypass procedures are similar for both adolescents and adults, according to data presented by Mike K. Chen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A multicenter review of 37 adolescents who underwent the procedure showed that average body mass index decreased by 20.7 kg/m

“While there are considerable risks with bariatric surgery, early experience suggests that these risks are offset by health benefits in these patients,” Dr. Chen said.

Five surgeons performed the operations on adolescents aged 13–21 years at three pediatric centers: Dr. Chen's institution, Children's Hospital of Alabama (University of Alabama, Birmingham), and Cincinnati Children's Hospital Medical Center (University of Cincinnati).

In 36 cases, the surgeons attempted laparoscopic procedures. Two were converted to open procedures, however, bringing to three the number of open procedures in the sample. Roux limb lengths were reported as 75–150 cm, and gastric pouch size as 30–45 cc.

Average body mass index at baseline was 56.5 kg/m

Dr. Chen itemized the metabolic data as follows: fasting insulin decreased by 21.3 μU/mL in 14 patients, fasting glucose by 12 g/dL in 10 patients, homeostasis model assessment-insulin resistance (HOMA-IR) by 4.6 in 9 patients, triglycerides by 65.1 mg/dL in 17 patients, and total cholesterol by 29.7 mg/dL in 18 patients.

Because of the small sample size, Dr. Chen and his coauthors did not calculate rates for individual complications but reported adverse events in categories.

They classified a complication as minor if the patient was readmitted to the hospital for less than 7 days of treatment, which could be endoscopy or diagnostic studies. Nine adolescents had minor complications, identified as endoscopy, food obstruction, wound infection, stricture, dumping syndrome secondary to overeating, mild beriberi that responded to outpatient treatment, hypokalemia, and deep vein thrombosis.

The investigators defined a moderate complication as unanticipated admission to an intensive care unit, reoperation, or sequelae lasting 7–30 days. Four patients had moderate complications. Dr. Chen listed these as persistent iron deficiency anemia, peripheral neuropathy secondary to vitamin deficiency, reoperation, shock, or internal hernia. He said the reasons for reoperation were staple line leak, obstruction, and gastrostomy revision.

A severe complication could be a life-threatening event, a major organ system failure, or sequelae lasting more than 30 days. Only two patients had a severe complication: a teenager who died 9 months after surgery from colitis that developed during rehabilitation for osteoarthritis, and one who experienced beriberi with sequelae for 2 months. The rest of the complications were mild to moderate, and 22 patients (61%) had none at all.

Dr. Chen said the surgeons undertook the analysis in response to a call for outcome studies in recently published guidelines for bariatric surgery in patients between the ages of 13 and 21 (Pediatrics 2004;114:217–23).

He cited one previous report of efficacy and complication rates, noting it was limited to 33 adolescents treated over 20 years at a single adult institution (J. Gastrointest. Surg. 2003;7:102–7).

“The vast majority of patients who undergo bariatric surgery are adults in their fifth decade of life,” Dr. Chen said, adding that outcome data clearly support the procedure's efficacy in the older population.

About 15.5% of adolescents are overweight, he said, adding that “50%–75% of these obese kids become obese adults.” Without a successful intervention, he warned, the consequences can include physical and psychosocial conditions and lost years of life.

PHOENIX — Benefits and complications resulting from Roux-en-Y gastric bypass procedures are similar for both adolescents and adults, according to data presented by Mike K. Chen, M.D., at the annual meeting of the American Pediatric Surgical Association.

A multicenter review of 37 adolescents who underwent the procedure showed that average body mass index decreased by 20.7 kg/m

“While there are considerable risks with bariatric surgery, early experience suggests that these risks are offset by health benefits in these patients,” Dr. Chen said.

Five surgeons performed the operations on adolescents aged 13–21 years at three pediatric centers: Dr. Chen's institution, Children's Hospital of Alabama (University of Alabama, Birmingham), and Cincinnati Children's Hospital Medical Center (University of Cincinnati).

In 36 cases, the surgeons attempted laparoscopic procedures. Two were converted to open procedures, however, bringing to three the number of open procedures in the sample. Roux limb lengths were reported as 75–150 cm, and gastric pouch size as 30–45 cc.

Average body mass index at baseline was 56.5 kg/m

Dr. Chen itemized the metabolic data as follows: fasting insulin decreased by 21.3 μU/mL in 14 patients, fasting glucose by 12 g/dL in 10 patients, homeostasis model assessment-insulin resistance (HOMA-IR) by 4.6 in 9 patients, triglycerides by 65.1 mg/dL in 17 patients, and total cholesterol by 29.7 mg/dL in 18 patients.

Because of the small sample size, Dr. Chen and his coauthors did not calculate rates for individual complications but reported adverse events in categories.

They classified a complication as minor if the patient was readmitted to the hospital for less than 7 days of treatment, which could be endoscopy or diagnostic studies. Nine adolescents had minor complications, identified as endoscopy, food obstruction, wound infection, stricture, dumping syndrome secondary to overeating, mild beriberi that responded to outpatient treatment, hypokalemia, and deep vein thrombosis.

The investigators defined a moderate complication as unanticipated admission to an intensive care unit, reoperation, or sequelae lasting 7–30 days. Four patients had moderate complications. Dr. Chen listed these as persistent iron deficiency anemia, peripheral neuropathy secondary to vitamin deficiency, reoperation, shock, or internal hernia. He said the reasons for reoperation were staple line leak, obstruction, and gastrostomy revision.

A severe complication could be a life-threatening event, a major organ system failure, or sequelae lasting more than 30 days. Only two patients had a severe complication: a teenager who died 9 months after surgery from colitis that developed during rehabilitation for osteoarthritis, and one who experienced beriberi with sequelae for 2 months. The rest of the complications were mild to moderate, and 22 patients (61%) had none at all.

Dr. Chen said the surgeons undertook the analysis in response to a call for outcome studies in recently published guidelines for bariatric surgery in patients between the ages of 13 and 21 (Pediatrics 2004;114:217–23).

He cited one previous report of efficacy and complication rates, noting it was limited to 33 adolescents treated over 20 years at a single adult institution (J. Gastrointest. Surg. 2003;7:102–7).

“The vast majority of patients who undergo bariatric surgery are adults in their fifth decade of life,” Dr. Chen said, adding that outcome data clearly support the procedure's efficacy in the older population.

About 15.5% of adolescents are overweight, he said, adding that “50%–75% of these obese kids become obese adults.” Without a successful intervention, he warned, the consequences can include physical and psychosocial conditions and lost years of life.

ASPEN, COLO. — Stool cultures cost millions of dollars annually, but rarely turn up meaningful information for physicians managing diarrhea in the United States, according to Ann-Christine Nyquist, M.D.

Physicians should only order cultures when the results would affect treatment or if they suspect an infectious disease outbreak, she advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“Is it going to make a difference in what you are going to do with that patient—whether you treat or not? You are probably going to treat symptomatically,” said Dr. Nyquist, the hospital's medical director of infection control.

She cited a review of 598 cultures done in pediatric hospital patients. Only 18 (3%) were positive (Arch. Pediatr. Adolesc. Med. 1997;151:142–5). Extrapolating the $26,084 cost of these negative tests against 1990 census data for hospitalized children aged 14 and under, Dr. Nyquist suggested that more than $45 million a year was being thrown away on negative stool tests for this population.

More useful information can be obtained from patient history, she said, urging physicians to be thorough in their questioning. “You really want to get to the nitty-gritty of what did the poop look like. … Eighty percent of the story can be gotten by looking at the history,” she said.

Focusing on epidemiologic risk factors in children, she suggested questions about travel to a developing area, day care, pets and petting zoos, unsafe foods, swimming in or drinking fresh untreated surface water, knowing other ill people, medications, and underlying medical conditions. Ask about contact with reptiles, she advised.

Review of clinical and epidemiologic features should include whether the illness had an abrupt or gradual onset, duration of symptoms, frequency of bowel movements, and relative quantity of stool produced, according to Dr. Nyquist, also of the University of Colorado, Denver.

Specific questions about stool characteristics should focus on such features as “watery, bloody, mucous, purulent, greasy, etc.,” she said. Be sure to ask about dysenteric symptoms, such as “fever, tenesmus, blood and/or pus in the stool”; symptoms of volume depletion; and associated symptoms, such as “nausea, vomiting, abdominal pain, cramps, headache, myalgia, or altered sensorium.”

Recent travel abroad is one of four criteria in an evidence- and consensus-based guideline cited by Dr. Nyquist for ordering a stool culture. The others are “history of blood with or without mucus in stool, [being] systematically unwell, severe or prolonged diarrhea, [and] a history suggestive of food poisoning” (Arch. Dis. Child. 2001;85:132–42).

Tests should be ordered selectively, starting with the most likely pathogens, she said. About 80% of traveler's diarrhea is caused by a bacterial agent, according to Dr. Nyquist. It can occur in the United States. without travel to a developing country.

The parasitic agents Giardia lamblia and Cryptosporidium also are common causes for which new tests are available. Among the viral causes of diarrhea, she identified rotavirus as the leader with 3.5 million episodes occurring annually each year in the United States. Not detectable by routine viral cultures, it requires more expensive tests.

Dr. Nyquist urged caution with empiric use of antimicrobial agents, and warned that most experts advise against using antibiotics in patients with bloody stool.

Antibiotics might induce disease-producing phage in some cases, she said, and they may worsen the risk of postdiarrheal hemolytic uremic syndrome in patients with shiga toxin Escherichia coli infections.

Treatment options discussed by Dr. Nyquist included rifaximin for simple traveler's diarrhea (but not in complex cases with bloody stool); tinidazole, a new agent for parasitic diseases; and Alinia (active ingredient nitazoxanide), which is approved for pediatric diarrhea caused by Cryptosporidium or Giardia intestinalis.

Physician use of soap and water is also very important, according to Dr. Nyquist. Rotavirus can survive for days on hospital surfaces (which must be cleaned with a bleach solution), and hand-washing gels are not effective against Clostridium difficile.

In all cases, no matter what the cause, she added, “if your hands are visibly soiled, you need to use soap and water.”

ASPEN, COLO. — Stool cultures cost millions of dollars annually, but rarely turn up meaningful information for physicians managing diarrhea in the United States, according to Ann-Christine Nyquist, M.D.

Physicians should only order cultures when the results would affect treatment or if they suspect an infectious disease outbreak, she advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“Is it going to make a difference in what you are going to do with that patient—whether you treat or not? You are probably going to treat symptomatically,” said Dr. Nyquist, the hospital's medical director of infection control.

She cited a review of 598 cultures done in pediatric hospital patients. Only 18 (3%) were positive (Arch. Pediatr. Adolesc. Med. 1997;151:142–5). Extrapolating the $26,084 cost of these negative tests against 1990 census data for hospitalized children aged 14 and under, Dr. Nyquist suggested that more than $45 million a year was being thrown away on negative stool tests for this population.

More useful information can be obtained from patient history, she said, urging physicians to be thorough in their questioning. “You really want to get to the nitty-gritty of what did the poop look like. … Eighty percent of the story can be gotten by looking at the history,” she said.

Focusing on epidemiologic risk factors in children, she suggested questions about travel to a developing area, day care, pets and petting zoos, unsafe foods, swimming in or drinking fresh untreated surface water, knowing other ill people, medications, and underlying medical conditions. Ask about contact with reptiles, she advised.

Review of clinical and epidemiologic features should include whether the illness had an abrupt or gradual onset, duration of symptoms, frequency of bowel movements, and relative quantity of stool produced, according to Dr. Nyquist, also of the University of Colorado, Denver.

Specific questions about stool characteristics should focus on such features as “watery, bloody, mucous, purulent, greasy, etc.,” she said. Be sure to ask about dysenteric symptoms, such as “fever, tenesmus, blood and/or pus in the stool”; symptoms of volume depletion; and associated symptoms, such as “nausea, vomiting, abdominal pain, cramps, headache, myalgia, or altered sensorium.”

Recent travel abroad is one of four criteria in an evidence- and consensus-based guideline cited by Dr. Nyquist for ordering a stool culture. The others are “history of blood with or without mucus in stool, [being] systematically unwell, severe or prolonged diarrhea, [and] a history suggestive of food poisoning” (Arch. Dis. Child. 2001;85:132–42).

Tests should be ordered selectively, starting with the most likely pathogens, she said. About 80% of traveler's diarrhea is caused by a bacterial agent, according to Dr. Nyquist. It can occur in the United States. without travel to a developing country.

The parasitic agents Giardia lamblia and Cryptosporidium also are common causes for which new tests are available. Among the viral causes of diarrhea, she identified rotavirus as the leader with 3.5 million episodes occurring annually each year in the United States. Not detectable by routine viral cultures, it requires more expensive tests.

Dr. Nyquist urged caution with empiric use of antimicrobial agents, and warned that most experts advise against using antibiotics in patients with bloody stool.

Antibiotics might induce disease-producing phage in some cases, she said, and they may worsen the risk of postdiarrheal hemolytic uremic syndrome in patients with shiga toxin Escherichia coli infections.

Treatment options discussed by Dr. Nyquist included rifaximin for simple traveler's diarrhea (but not in complex cases with bloody stool); tinidazole, a new agent for parasitic diseases; and Alinia (active ingredient nitazoxanide), which is approved for pediatric diarrhea caused by Cryptosporidium or Giardia intestinalis.

Physician use of soap and water is also very important, according to Dr. Nyquist. Rotavirus can survive for days on hospital surfaces (which must be cleaned with a bleach solution), and hand-washing gels are not effective against Clostridium difficile.

In all cases, no matter what the cause, she added, “if your hands are visibly soiled, you need to use soap and water.”

ASPEN, COLO. — Stool cultures cost millions of dollars annually, but rarely turn up meaningful information for physicians managing diarrhea in the United States, according to Ann-Christine Nyquist, M.D.

Physicians should only order cultures when the results would affect treatment or if they suspect an infectious disease outbreak, she advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“Is it going to make a difference in what you are going to do with that patient—whether you treat or not? You are probably going to treat symptomatically,” said Dr. Nyquist, the hospital's medical director of infection control.

She cited a review of 598 cultures done in pediatric hospital patients. Only 18 (3%) were positive (Arch. Pediatr. Adolesc. Med. 1997;151:142–5). Extrapolating the $26,084 cost of these negative tests against 1990 census data for hospitalized children aged 14 and under, Dr. Nyquist suggested that more than $45 million a year was being thrown away on negative stool tests for this population.

More useful information can be obtained from patient history, she said, urging physicians to be thorough in their questioning. “You really want to get to the nitty-gritty of what did the poop look like. … Eighty percent of the story can be gotten by looking at the history,” she said.

Focusing on epidemiologic risk factors in children, she suggested questions about travel to a developing area, day care, pets and petting zoos, unsafe foods, swimming in or drinking fresh untreated surface water, knowing other ill people, medications, and underlying medical conditions. Ask about contact with reptiles, she advised.

Review of clinical and epidemiologic features should include whether the illness had an abrupt or gradual onset, duration of symptoms, frequency of bowel movements, and relative quantity of stool produced, according to Dr. Nyquist, also of the University of Colorado, Denver.

Specific questions about stool characteristics should focus on such features as “watery, bloody, mucous, purulent, greasy, etc.,” she said. Be sure to ask about dysenteric symptoms, such as “fever, tenesmus, blood and/or pus in the stool”; symptoms of volume depletion; and associated symptoms, such as “nausea, vomiting, abdominal pain, cramps, headache, myalgia, or altered sensorium.”

Recent travel abroad is one of four criteria in an evidence- and consensus-based guideline cited by Dr. Nyquist for ordering a stool culture. The others are “history of blood with or without mucus in stool, [being] systematically unwell, severe or prolonged diarrhea, [and] a history suggestive of food poisoning” (Arch. Dis. Child. 2001;85:132–42).

Tests should be ordered selectively, starting with the most likely pathogens, she said. About 80% of traveler's diarrhea is caused by a bacterial agent, according to Dr. Nyquist. It can occur in the United States. without travel to a developing country.

The parasitic agents Giardia lamblia and Cryptosporidium also are common causes for which new tests are available. Among the viral causes of diarrhea, she identified rotavirus as the leader with 3.5 million episodes occurring annually each year in the United States. Not detectable by routine viral cultures, it requires more expensive tests.

Dr. Nyquist urged caution with empiric use of antimicrobial agents, and warned that most experts advise against using antibiotics in patients with bloody stool.

Antibiotics might induce disease-producing phage in some cases, she said, and they may worsen the risk of postdiarrheal hemolytic uremic syndrome in patients with shiga toxin Escherichia coli infections.

Treatment options discussed by Dr. Nyquist included rifaximin for simple traveler's diarrhea (but not in complex cases with bloody stool); tinidazole, a new agent for parasitic diseases; and Alinia (active ingredient nitazoxanide), which is approved for pediatric diarrhea caused by Cryptosporidium or Giardia intestinalis.

Physician use of soap and water is also very important, according to Dr. Nyquist. Rotavirus can survive for days on hospital surfaces (which must be cleaned with a bleach solution), and hand-washing gels are not effective against Clostridium difficile.

In all cases, no matter what the cause, she added, “if your hands are visibly soiled, you need to use soap and water.”

PHOENIX — Pediatric surgeons performing bariatric surgery on adolescents are encountering challenges not faced before in children's centers, according to presentations by leaders in the field at the annual meeting of the American Pediatric Surgical Association.

“A lot of work goes into this, a lot more than I ever, ever thought,” Michael A. Helmrath, M.D., said, showing before-and-after photographs of his first teenaged patient during a symposium on bariatric surgery at the meeting.

A pediatric surgeon at Texas Children's Hospital Clinical Care Center in Houston, Dr. Helmrath warned of “a steep learning curve” and urged his pediatric colleagues to do their first procedures at the side of a surgeon experienced in bariatric surgery for adults. “Mentorship is important,” he advised. “It is not just you that you are training. It is your entire operating team.”

Symposium speaker Thomas H. Inge, M.D., Ph.D., concurred with Dr. Helmrath's advice. For physicians and surgeons, training requirements will far exceed their previous experience in pediatric surgery, said Dr. Inge, director of bariatric research and surgical director of the Comprehensive Weight Management Center at Cincinnati Children's Hospital Medical Center in Ohio.

Taking an annual continuing medical education course is not sufficient, Dr. Inge said, describing bariatric surgery as “one of the most complex abdominal operations done.”

Just how many bariatric operations have been done on adolescents is not known. Walter J. Pories, M.D., estimated the number of Roux-en-Y gastric bypass procedures as 200–300 in an interview with this newspaper. Dr. Pories, a professor at East Carolina University, Greenville, North Carolina, is head of the Surgical Review Corporation, a nonprofit group created to designate centers of excellence in bariatric surgery.

Although patients under age 18 cannot consent legally, Dr. Helmrath said he requires adolescents to write a letter of assent by hand before he will operate. The letter states that they know they are going to have the operation, what the complications are, and what they need to do. The patients and their parents sign the letter, he said. “If I'm not satisfied, they rewrite it.”

Patient education requires a major effort, Dr. Inge said. He advocated group seminars and one-on-one instruction to ensure adolescents “are fully aware of what they are getting themselves into.”

Dr. Inge emphasized that leadership has to be multidisciplinary and that financial buy-in from the hospital administration is vital. Some essential program components will not be covered by insurance, he warned, and investments in equipment and facilities will be necessary.

Dr. Inge gave a list of examples, starting with gurneys and tables that can support a 535-lb patient. He recommended that hospitals buy a HoverMatt Air Transfer mattress or comparable product to allow staff to move obese patients without injury. Oversized 10X gowns should be readily available, he said, and heavy-duty, extrawide chairs and pedestal-mounted commodes are necessary for family members and patients alike.

Other areas of the hospital also have to make adjustments, according to Dr. Inge. The radiology department, for example, needs to be able to accommodate a still-oversized patient who returns to the hospital with acute abdominal pain after bariatric surgery. Radiology and emergency department staff need to become familiar with specific techniques and life-threatening complications not usually seen in a pediatric setting, he said.

“These are things we are not used to thinking about in pediatric hospitals, but we really must think about,” he said.

The bariatric surgery group will also have to put staff in place to monitor patients and to help them with weight loss, weight gain, and other outcomes after surgery. Long-term postsurgical follow-up of the young patients represents a paradigm shift in duration of care, Dr. Inge said. “This is care for the rest of one's life.”

During another discussion at the meeting, Allen F. Browne, M.D., said the Food and Drug Administration has authorized his group at the University of Illinois Medical Center, Chicago, to test the adjustable gastric band in 50 obese adolescents. The FDA approved the band as an alternative bariatric procedure for adults in 2001.

PHOENIX — Pediatric surgeons performing bariatric surgery on adolescents are encountering challenges not faced before in children's centers, according to presentations by leaders in the field at the annual meeting of the American Pediatric Surgical Association.

“A lot of work goes into this, a lot more than I ever, ever thought,” Michael A. Helmrath, M.D., said, showing before-and-after photographs of his first teenaged patient during a symposium on bariatric surgery at the meeting.

A pediatric surgeon at Texas Children's Hospital Clinical Care Center in Houston, Dr. Helmrath warned of “a steep learning curve” and urged his pediatric colleagues to do their first procedures at the side of a surgeon experienced in bariatric surgery for adults. “Mentorship is important,” he advised. “It is not just you that you are training. It is your entire operating team.”

Symposium speaker Thomas H. Inge, M.D., Ph.D., concurred with Dr. Helmrath's advice. For physicians and surgeons, training requirements will far exceed their previous experience in pediatric surgery, said Dr. Inge, director of bariatric research and surgical director of the Comprehensive Weight Management Center at Cincinnati Children's Hospital Medical Center in Ohio.

Taking an annual continuing medical education course is not sufficient, Dr. Inge said, describing bariatric surgery as “one of the most complex abdominal operations done.”

Just how many bariatric operations have been done on adolescents is not known. Walter J. Pories, M.D., estimated the number of Roux-en-Y gastric bypass procedures as 200–300 in an interview with this newspaper. Dr. Pories, a professor at East Carolina University, Greenville, North Carolina, is head of the Surgical Review Corporation, a nonprofit group created to designate centers of excellence in bariatric surgery.

Although patients under age 18 cannot consent legally, Dr. Helmrath said he requires adolescents to write a letter of assent by hand before he will operate. The letter states that they know they are going to have the operation, what the complications are, and what they need to do. The patients and their parents sign the letter, he said. “If I'm not satisfied, they rewrite it.”

Patient education requires a major effort, Dr. Inge said. He advocated group seminars and one-on-one instruction to ensure adolescents “are fully aware of what they are getting themselves into.”

Dr. Inge emphasized that leadership has to be multidisciplinary and that financial buy-in from the hospital administration is vital. Some essential program components will not be covered by insurance, he warned, and investments in equipment and facilities will be necessary.

Dr. Inge gave a list of examples, starting with gurneys and tables that can support a 535-lb patient. He recommended that hospitals buy a HoverMatt Air Transfer mattress or comparable product to allow staff to move obese patients without injury. Oversized 10X gowns should be readily available, he said, and heavy-duty, extrawide chairs and pedestal-mounted commodes are necessary for family members and patients alike.

Other areas of the hospital also have to make adjustments, according to Dr. Inge. The radiology department, for example, needs to be able to accommodate a still-oversized patient who returns to the hospital with acute abdominal pain after bariatric surgery. Radiology and emergency department staff need to become familiar with specific techniques and life-threatening complications not usually seen in a pediatric setting, he said.

“These are things we are not used to thinking about in pediatric hospitals, but we really must think about,” he said.

The bariatric surgery group will also have to put staff in place to monitor patients and to help them with weight loss, weight gain, and other outcomes after surgery. Long-term postsurgical follow-up of the young patients represents a paradigm shift in duration of care, Dr. Inge said. “This is care for the rest of one's life.”

During another discussion at the meeting, Allen F. Browne, M.D., said the Food and Drug Administration has authorized his group at the University of Illinois Medical Center, Chicago, to test the adjustable gastric band in 50 obese adolescents. The FDA approved the band as an alternative bariatric procedure for adults in 2001.

PHOENIX — Pediatric surgeons performing bariatric surgery on adolescents are encountering challenges not faced before in children's centers, according to presentations by leaders in the field at the annual meeting of the American Pediatric Surgical Association.

“A lot of work goes into this, a lot more than I ever, ever thought,” Michael A. Helmrath, M.D., said, showing before-and-after photographs of his first teenaged patient during a symposium on bariatric surgery at the meeting.

A pediatric surgeon at Texas Children's Hospital Clinical Care Center in Houston, Dr. Helmrath warned of “a steep learning curve” and urged his pediatric colleagues to do their first procedures at the side of a surgeon experienced in bariatric surgery for adults. “Mentorship is important,” he advised. “It is not just you that you are training. It is your entire operating team.”

Symposium speaker Thomas H. Inge, M.D., Ph.D., concurred with Dr. Helmrath's advice. For physicians and surgeons, training requirements will far exceed their previous experience in pediatric surgery, said Dr. Inge, director of bariatric research and surgical director of the Comprehensive Weight Management Center at Cincinnati Children's Hospital Medical Center in Ohio.

Taking an annual continuing medical education course is not sufficient, Dr. Inge said, describing bariatric surgery as “one of the most complex abdominal operations done.”

Just how many bariatric operations have been done on adolescents is not known. Walter J. Pories, M.D., estimated the number of Roux-en-Y gastric bypass procedures as 200–300 in an interview with this newspaper. Dr. Pories, a professor at East Carolina University, Greenville, North Carolina, is head of the Surgical Review Corporation, a nonprofit group created to designate centers of excellence in bariatric surgery.

Although patients under age 18 cannot consent legally, Dr. Helmrath said he requires adolescents to write a letter of assent by hand before he will operate. The letter states that they know they are going to have the operation, what the complications are, and what they need to do. The patients and their parents sign the letter, he said. “If I'm not satisfied, they rewrite it.”

Patient education requires a major effort, Dr. Inge said. He advocated group seminars and one-on-one instruction to ensure adolescents “are fully aware of what they are getting themselves into.”

Dr. Inge emphasized that leadership has to be multidisciplinary and that financial buy-in from the hospital administration is vital. Some essential program components will not be covered by insurance, he warned, and investments in equipment and facilities will be necessary.

Dr. Inge gave a list of examples, starting with gurneys and tables that can support a 535-lb patient. He recommended that hospitals buy a HoverMatt Air Transfer mattress or comparable product to allow staff to move obese patients without injury. Oversized 10X gowns should be readily available, he said, and heavy-duty, extrawide chairs and pedestal-mounted commodes are necessary for family members and patients alike.

Other areas of the hospital also have to make adjustments, according to Dr. Inge. The radiology department, for example, needs to be able to accommodate a still-oversized patient who returns to the hospital with acute abdominal pain after bariatric surgery. Radiology and emergency department staff need to become familiar with specific techniques and life-threatening complications not usually seen in a pediatric setting, he said.

“These are things we are not used to thinking about in pediatric hospitals, but we really must think about,” he said.

The bariatric surgery group will also have to put staff in place to monitor patients and to help them with weight loss, weight gain, and other outcomes after surgery. Long-term postsurgical follow-up of the young patients represents a paradigm shift in duration of care, Dr. Inge said. “This is care for the rest of one's life.”

During another discussion at the meeting, Allen F. Browne, M.D., said the Food and Drug Administration has authorized his group at the University of Illinois Medical Center, Chicago, to test the adjustable gastric band in 50 obese adolescents. The FDA approved the band as an alternative bariatric procedure for adults in 2001.

ASPEN, COLO. — Two groups of immunocompromised children present special challenges in community-based practices, Elizabeth J. McFarland, M.D., said at a conference on pediatric infectious diseases, sponsored by Children's Hospital, Denver.

Weakened immune systems can make some vaccinations worrisome for youngsters taking high-dose steroids to control asthma and can make other vaccinations vital for children without a spleen, said Dr. McFarland, director of the hospital's immunodeficiency clinic.

Even more serious, she warned, is the risk of sepsis, with high mortality rates from postsplenectomy sepsis. Half of sepsis cases occur within 2 years of spleen removal, but 3% have been documented 20 years afterward (Br. J. Surg. 1991;78:1031–8).

Asthma and Steroid Issues

Dr. McFarland acknowledged that steroids are “important drugs” for controlling asthma. The problem is that by interfering with cytokine production and lessening immune cell activity, steroids reduce the body's “ability to mount immune response or react to vaccine.”

According to Dr. McFarland, the American Academy of Pediatrics supports giving inactivated virus vaccines to children who are prescribed steroids, but she cautions that immunogenicity is uncertain. Live virus vaccines should be delayed until high-dose steroids are stopped.

If children take a high-dose steroid daily or on alternate days for more than 14 days, doctors should wait 1 month after stopping steroid use before giving vaccines, Dr. McFarland said. She also said that if the dosage period is less than 14 days, live virus vaccines can be given after stopping, but some experts recommend waiting 2 weeks.

AAP recommends inactivated influenza vaccine for patients with asthma. Dr. McFarland said studies have shown similar antibody responses to the influenza vaccine in patients receiving inhaled steroids and short-course oral steroids, when compared with patients not receiving steroids at the time of immunization.

The live varicella zoster virus (VZV) vaccine is not recommended during high-dose steroid use, because vaccine safety is not established in this population. However, Dr. McFarland said a health maintenance organization study found that inhaled steroids given 3 months prior to VZV vaccination were not associated with increased risk of breakthrough disease (Pediatrics 2003;112:e98-e113), but the study did find increased breakthrough disease after VZV vaccination when oral steroids were given in the 3 months prior.

Postsplenectomy Issues

European studies have shown that about a quarter of physicians do not comply with guidelines for postsplenectomy care, Dr. McFarland said. She could not find any similar studies in the United States.

Although splenectomies in children may be necessary after trauma, she said the operation is being done less often owing to greater recognition of the spleen's importance to immune defense and to newer splenic salvage techniques.

Dr. McFarland urged pneumococcal vaccination for postsplenectomy patients. About two-thirds of sepsis cases have been traced to Streptococcus pneumoniae in this population.

If the regular pneumococcal conjugate vaccine (PCV) series was not given before age 24 months, doctors should give two doses of PCV, she said. She recommended one dose of pneumococcal polysaccharide vaccine 6–8 weeks after PCV, and a second dose 3–5 years afterward.

Postsplenectomy patients also should be vaccinated against meningococcus, according to Dr. McFarland. The new meningococcal conjugate vaccine (MCV4) is preferred for patients aged 11–55; only meningococcal polysaccharide vaccine (MPSV4) is approved for patients aged 2–11. Optimally, vaccinations for the encapsulated bacteria should be given prior to a planned splenectomy.

She suggested giving an extra dose of Haemophilus influenzae type b (Hib) vaccine prior to splenectomy, if possible. Afterward, these children also should receive annual influenza shots, she said.

Daily antibiotic prophylaxis is recommended, especially in the first 2 years after splenectomy. However, Dr. McFarland said the randomized studies supporting its use were performed in young sickle cell anemia patients with functional asplenia.

Determining when to discontinue daily prophylaxis is difficult, she said, as there are no direct data for children with splenectomies. Physicians should discuss the risks and benefits with their patients. The recommended dosages are 125 mg of penicillin V twice daily in children under age 5 and 250 mg twice daily in children over age 5; some experts use amoxicillin (20 mg/kg daily).

Empiric therapy is another option, often used if daily prophylaxis is discontinued. At the first sign of a fever, the parents administer a dose of oral antibiotics and then bring in the child “pronto” for further evaluation. Dr. McFarland recommended 50 mg/kg of amoxicillin/clavulanate potassium (Augmentin) divided into 2–3 dosages daily or an alternative, possibly a cephalosporin, if the child is allergic to penicillin.

Pneumococcal resistance to penicillin is a concern, she said, and she urged physicians to find out the rate in their community. For sepsis cases, however, she recommended starting with vancomycin and a cephalosporin.

Without a spleen, patients also are at high risk for malaria and other insect-borne infections. Physicians should ask about mosquito and tick exposure.

Teach Parents About Zoonoses

Many physicians—Dr. McFarland among them—do not have the heart to banish all pets from the home of an immunocompromised child.

“The better you can take care of your animal … the less likely your pet will get sick,” is the message she urged physicians to give to parents of immunocompromised children. Keeping the animal healthy will help the child stay well.

Dr. McFarland said the U.S. Public Health Service has identified five zoonoses of particular concern that immunocompromised children can pick up from animals: salmonellosis, campylobacteriosis, bacillary angiomatosis (Bartonella henselae, or cat scratch disease), cryptosporidiosis, and toxoplasmosis.

Countering these risks, she summarized the benefits of pet ownership, including decreased loneliness and increased feeling of intimacy and constancy.

The first principle of pet safety, she said, is to buy or adopt a healthy animal, preferably an adult. Young animals are more vulnerable to pathogens. No animal with diarrhea should be handled by the child.

Second, keep the animal healthy by preventing exposure to pathogens. For example, don't let a cat or dog roam. Fleas and ticks are a concern, as well as exposure to other animals and their feces, and anything else the pet might eat off the street.

Keep the animal inside, and keep the toilet seat down so the pet does not use the fixture as a fountain. Feed the animal well, and make sure it does not get into the garbage.

Third, avoid all contact with feces.

Dr. McFarland offered additional recommendations for patients, including children, who undergo hematopoietic stem cell transplants (MMWR 2000;49(RR10):1–128). Parents should be advised of the risks, but children don't need to be forced to part with their pets.

Animals should be fed high-quality commercial pet food, according to Dr. McFarland. All dairy foods should be pasteurized, and any foods containing eggs, poultry, or meat should be well cooked.

Stem cell recipients should always wash their hands after handling an animal. Someone else should clean a cage, a litter box, or a fish tank while the patient is immunocompromised. Litter boxes should be cleaned daily and kept away from food preparation or eating areas.

At the first suspicion of a pet's illness, the animal should be taken to the vet, Dr. McFarland said.

Even with these precautions, some animals are prohibited as pets. She listed all reptiles (with a warning against reptile fomites), ducklings or chicks, and exotic pets, including nonhuman primates.

“Kissing frogs is not recommended,” she said; kissing dogs, cats, and other household pets also is discouraged.

For more information, including brochures to download, Dr. McFarland recommended referring parents to

www.cdc.gov/healthypets

ASPEN, COLO. — Two groups of immunocompromised children present special challenges in community-based practices, Elizabeth J. McFarland, M.D., said at a conference on pediatric infectious diseases, sponsored by Children's Hospital, Denver.

Weakened immune systems can make some vaccinations worrisome for youngsters taking high-dose steroids to control asthma and can make other vaccinations vital for children without a spleen, said Dr. McFarland, director of the hospital's immunodeficiency clinic.

Even more serious, she warned, is the risk of sepsis, with high mortality rates from postsplenectomy sepsis. Half of sepsis cases occur within 2 years of spleen removal, but 3% have been documented 20 years afterward (Br. J. Surg. 1991;78:1031–8).

Asthma and Steroid Issues

Dr. McFarland acknowledged that steroids are “important drugs” for controlling asthma. The problem is that by interfering with cytokine production and lessening immune cell activity, steroids reduce the body's “ability to mount immune response or react to vaccine.”

According to Dr. McFarland, the American Academy of Pediatrics supports giving inactivated virus vaccines to children who are prescribed steroids, but she cautions that immunogenicity is uncertain. Live virus vaccines should be delayed until high-dose steroids are stopped.

If children take a high-dose steroid daily or on alternate days for more than 14 days, doctors should wait 1 month after stopping steroid use before giving vaccines, Dr. McFarland said. She also said that if the dosage period is less than 14 days, live virus vaccines can be given after stopping, but some experts recommend waiting 2 weeks.

AAP recommends inactivated influenza vaccine for patients with asthma. Dr. McFarland said studies have shown similar antibody responses to the influenza vaccine in patients receiving inhaled steroids and short-course oral steroids, when compared with patients not receiving steroids at the time of immunization.

The live varicella zoster virus (VZV) vaccine is not recommended during high-dose steroid use, because vaccine safety is not established in this population. However, Dr. McFarland said a health maintenance organization study found that inhaled steroids given 3 months prior to VZV vaccination were not associated with increased risk of breakthrough disease (Pediatrics 2003;112:e98-e113), but the study did find increased breakthrough disease after VZV vaccination when oral steroids were given in the 3 months prior.

Postsplenectomy Issues

European studies have shown that about a quarter of physicians do not comply with guidelines for postsplenectomy care, Dr. McFarland said. She could not find any similar studies in the United States.

Although splenectomies in children may be necessary after trauma, she said the operation is being done less often owing to greater recognition of the spleen's importance to immune defense and to newer splenic salvage techniques.

Dr. McFarland urged pneumococcal vaccination for postsplenectomy patients. About two-thirds of sepsis cases have been traced to Streptococcus pneumoniae in this population.

If the regular pneumococcal conjugate vaccine (PCV) series was not given before age 24 months, doctors should give two doses of PCV, she said. She recommended one dose of pneumococcal polysaccharide vaccine 6–8 weeks after PCV, and a second dose 3–5 years afterward.

Postsplenectomy patients also should be vaccinated against meningococcus, according to Dr. McFarland. The new meningococcal conjugate vaccine (MCV4) is preferred for patients aged 11–55; only meningococcal polysaccharide vaccine (MPSV4) is approved for patients aged 2–11. Optimally, vaccinations for the encapsulated bacteria should be given prior to a planned splenectomy.

She suggested giving an extra dose of Haemophilus influenzae type b (Hib) vaccine prior to splenectomy, if possible. Afterward, these children also should receive annual influenza shots, she said.

Daily antibiotic prophylaxis is recommended, especially in the first 2 years after splenectomy. However, Dr. McFarland said the randomized studies supporting its use were performed in young sickle cell anemia patients with functional asplenia.

Determining when to discontinue daily prophylaxis is difficult, she said, as there are no direct data for children with splenectomies. Physicians should discuss the risks and benefits with their patients. The recommended dosages are 125 mg of penicillin V twice daily in children under age 5 and 250 mg twice daily in children over age 5; some experts use amoxicillin (20 mg/kg daily).

Empiric therapy is another option, often used if daily prophylaxis is discontinued. At the first sign of a fever, the parents administer a dose of oral antibiotics and then bring in the child “pronto” for further evaluation. Dr. McFarland recommended 50 mg/kg of amoxicillin/clavulanate potassium (Augmentin) divided into 2–3 dosages daily or an alternative, possibly a cephalosporin, if the child is allergic to penicillin.

Pneumococcal resistance to penicillin is a concern, she said, and she urged physicians to find out the rate in their community. For sepsis cases, however, she recommended starting with vancomycin and a cephalosporin.

Without a spleen, patients also are at high risk for malaria and other insect-borne infections. Physicians should ask about mosquito and tick exposure.

Teach Parents About Zoonoses

Many physicians—Dr. McFarland among them—do not have the heart to banish all pets from the home of an immunocompromised child.

“The better you can take care of your animal … the less likely your pet will get sick,” is the message she urged physicians to give to parents of immunocompromised children. Keeping the animal healthy will help the child stay well.

Dr. McFarland said the U.S. Public Health Service has identified five zoonoses of particular concern that immunocompromised children can pick up from animals: salmonellosis, campylobacteriosis, bacillary angiomatosis (Bartonella henselae, or cat scratch disease), cryptosporidiosis, and toxoplasmosis.

Countering these risks, she summarized the benefits of pet ownership, including decreased loneliness and increased feeling of intimacy and constancy.

The first principle of pet safety, she said, is to buy or adopt a healthy animal, preferably an adult. Young animals are more vulnerable to pathogens. No animal with diarrhea should be handled by the child.

Second, keep the animal healthy by preventing exposure to pathogens. For example, don't let a cat or dog roam. Fleas and ticks are a concern, as well as exposure to other animals and their feces, and anything else the pet might eat off the street.

Keep the animal inside, and keep the toilet seat down so the pet does not use the fixture as a fountain. Feed the animal well, and make sure it does not get into the garbage.

Third, avoid all contact with feces.

Dr. McFarland offered additional recommendations for patients, including children, who undergo hematopoietic stem cell transplants (MMWR 2000;49(RR10):1–128). Parents should be advised of the risks, but children don't need to be forced to part with their pets.

Animals should be fed high-quality commercial pet food, according to Dr. McFarland. All dairy foods should be pasteurized, and any foods containing eggs, poultry, or meat should be well cooked.

Stem cell recipients should always wash their hands after handling an animal. Someone else should clean a cage, a litter box, or a fish tank while the patient is immunocompromised. Litter boxes should be cleaned daily and kept away from food preparation or eating areas.

At the first suspicion of a pet's illness, the animal should be taken to the vet, Dr. McFarland said.

Even with these precautions, some animals are prohibited as pets. She listed all reptiles (with a warning against reptile fomites), ducklings or chicks, and exotic pets, including nonhuman primates.

“Kissing frogs is not recommended,” she said; kissing dogs, cats, and other household pets also is discouraged.

For more information, including brochures to download, Dr. McFarland recommended referring parents to

www.cdc.gov/healthypets

ASPEN, COLO. — Two groups of immunocompromised children present special challenges in community-based practices, Elizabeth J. McFarland, M.D., said at a conference on pediatric infectious diseases, sponsored by Children's Hospital, Denver.

Weakened immune systems can make some vaccinations worrisome for youngsters taking high-dose steroids to control asthma and can make other vaccinations vital for children without a spleen, said Dr. McFarland, director of the hospital's immunodeficiency clinic.

Even more serious, she warned, is the risk of sepsis, with high mortality rates from postsplenectomy sepsis. Half of sepsis cases occur within 2 years of spleen removal, but 3% have been documented 20 years afterward (Br. J. Surg. 1991;78:1031–8).

Asthma and Steroid Issues

Dr. McFarland acknowledged that steroids are “important drugs” for controlling asthma. The problem is that by interfering with cytokine production and lessening immune cell activity, steroids reduce the body's “ability to mount immune response or react to vaccine.”

According to Dr. McFarland, the American Academy of Pediatrics supports giving inactivated virus vaccines to children who are prescribed steroids, but she cautions that immunogenicity is uncertain. Live virus vaccines should be delayed until high-dose steroids are stopped.

If children take a high-dose steroid daily or on alternate days for more than 14 days, doctors should wait 1 month after stopping steroid use before giving vaccines, Dr. McFarland said. She also said that if the dosage period is less than 14 days, live virus vaccines can be given after stopping, but some experts recommend waiting 2 weeks.

AAP recommends inactivated influenza vaccine for patients with asthma. Dr. McFarland said studies have shown similar antibody responses to the influenza vaccine in patients receiving inhaled steroids and short-course oral steroids, when compared with patients not receiving steroids at the time of immunization.

The live varicella zoster virus (VZV) vaccine is not recommended during high-dose steroid use, because vaccine safety is not established in this population. However, Dr. McFarland said a health maintenance organization study found that inhaled steroids given 3 months prior to VZV vaccination were not associated with increased risk of breakthrough disease (Pediatrics 2003;112:e98-e113), but the study did find increased breakthrough disease after VZV vaccination when oral steroids were given in the 3 months prior.

Postsplenectomy Issues

European studies have shown that about a quarter of physicians do not comply with guidelines for postsplenectomy care, Dr. McFarland said. She could not find any similar studies in the United States.

Although splenectomies in children may be necessary after trauma, she said the operation is being done less often owing to greater recognition of the spleen's importance to immune defense and to newer splenic salvage techniques.

Dr. McFarland urged pneumococcal vaccination for postsplenectomy patients. About two-thirds of sepsis cases have been traced to Streptococcus pneumoniae in this population.

If the regular pneumococcal conjugate vaccine (PCV) series was not given before age 24 months, doctors should give two doses of PCV, she said. She recommended one dose of pneumococcal polysaccharide vaccine 6–8 weeks after PCV, and a second dose 3–5 years afterward.

Postsplenectomy patients also should be vaccinated against meningococcus, according to Dr. McFarland. The new meningococcal conjugate vaccine (MCV4) is preferred for patients aged 11–55; only meningococcal polysaccharide vaccine (MPSV4) is approved for patients aged 2–11. Optimally, vaccinations for the encapsulated bacteria should be given prior to a planned splenectomy.

She suggested giving an extra dose of Haemophilus influenzae type b (Hib) vaccine prior to splenectomy, if possible. Afterward, these children also should receive annual influenza shots, she said.

Daily antibiotic prophylaxis is recommended, especially in the first 2 years after splenectomy. However, Dr. McFarland said the randomized studies supporting its use were performed in young sickle cell anemia patients with functional asplenia.

Determining when to discontinue daily prophylaxis is difficult, she said, as there are no direct data for children with splenectomies. Physicians should discuss the risks and benefits with their patients. The recommended dosages are 125 mg of penicillin V twice daily in children under age 5 and 250 mg twice daily in children over age 5; some experts use amoxicillin (20 mg/kg daily).

Empiric therapy is another option, often used if daily prophylaxis is discontinued. At the first sign of a fever, the parents administer a dose of oral antibiotics and then bring in the child “pronto” for further evaluation. Dr. McFarland recommended 50 mg/kg of amoxicillin/clavulanate potassium (Augmentin) divided into 2–3 dosages daily or an alternative, possibly a cephalosporin, if the child is allergic to penicillin.

Pneumococcal resistance to penicillin is a concern, she said, and she urged physicians to find out the rate in their community. For sepsis cases, however, she recommended starting with vancomycin and a cephalosporin.

Without a spleen, patients also are at high risk for malaria and other insect-borne infections. Physicians should ask about mosquito and tick exposure.

Teach Parents About Zoonoses

Many physicians—Dr. McFarland among them—do not have the heart to banish all pets from the home of an immunocompromised child.

“The better you can take care of your animal … the less likely your pet will get sick,” is the message she urged physicians to give to parents of immunocompromised children. Keeping the animal healthy will help the child stay well.

Dr. McFarland said the U.S. Public Health Service has identified five zoonoses of particular concern that immunocompromised children can pick up from animals: salmonellosis, campylobacteriosis, bacillary angiomatosis (Bartonella henselae, or cat scratch disease), cryptosporidiosis, and toxoplasmosis.

Countering these risks, she summarized the benefits of pet ownership, including decreased loneliness and increased feeling of intimacy and constancy.

The first principle of pet safety, she said, is to buy or adopt a healthy animal, preferably an adult. Young animals are more vulnerable to pathogens. No animal with diarrhea should be handled by the child.

Second, keep the animal healthy by preventing exposure to pathogens. For example, don't let a cat or dog roam. Fleas and ticks are a concern, as well as exposure to other animals and their feces, and anything else the pet might eat off the street.

Keep the animal inside, and keep the toilet seat down so the pet does not use the fixture as a fountain. Feed the animal well, and make sure it does not get into the garbage.

Third, avoid all contact with feces.

Dr. McFarland offered additional recommendations for patients, including children, who undergo hematopoietic stem cell transplants (MMWR 2000;49(RR10):1–128). Parents should be advised of the risks, but children don't need to be forced to part with their pets.

Animals should be fed high-quality commercial pet food, according to Dr. McFarland. All dairy foods should be pasteurized, and any foods containing eggs, poultry, or meat should be well cooked.

Stem cell recipients should always wash their hands after handling an animal. Someone else should clean a cage, a litter box, or a fish tank while the patient is immunocompromised. Litter boxes should be cleaned daily and kept away from food preparation or eating areas.

At the first suspicion of a pet's illness, the animal should be taken to the vet, Dr. McFarland said.

Even with these precautions, some animals are prohibited as pets. She listed all reptiles (with a warning against reptile fomites), ducklings or chicks, and exotic pets, including nonhuman primates.

“Kissing frogs is not recommended,” she said; kissing dogs, cats, and other household pets also is discouraged.

For more information, including brochures to download, Dr. McFarland recommended referring parents to

www.cdc.gov/healthypets

ASPEN, COLO. — Routine vaccinations can be accelerated to protect very young travelers against infectious diseases in developing countries, Sarah K. Parker, M.D., advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“They can be really protected by about 131/2 months of age,” said Dr. Parker of Children's Hospital and a faculty member in pediatric infectious diseases at the University of Colorado Health Sciences Center, Denver.

Dr. Parker also recommended that physicians do a pretravel assessment to identify additional vaccination requirements by endemic conditions in destination countries. The assessment would include consideration of chemoprophylaxis and counseling parents on ways to prevent infectious disease while traveling abroad.

“Infection only causes about 1% of traveler deaths. However, it is a large fraction of what causes illness while traveling,” she said. About 50%–70% of travelers become ill. About 40% of illnesses are diarrhea, which can be more severe and more prolonged in children.

Routine vaccinations can start at 6 weeks of age, she said, outlining an accelerated schedule. Babies can receive four doses of inactivated polio vaccine; three doses of DTaP vaccine, Haemophilus influenzae type b vaccine, and seven-valent pneumococcal polysaccharide vaccine; and two doses of hepatitis B virus vaccine by 14 weeks.

MMR can be given at 6 months, she said, but does not count. If given at 12 months, it can be followed by a booster at 13 months. The accelerated schedule also permits hepatitis A virus vaccine off-label at 12 months.

A family traveling to Africa's “meningitis belt” should use the polysaccharide conjugate vaccine for children older than 11 years, the polysaccharide meningococcal vaccine for children 2–11 years, and consider its use off label in younger children at high risk, she said. The polysaccharide vaccine has been studied at 3 months with a 12-month booster with a rise in titers against meningococcus A, the predominant strain in Africa.

Varicella zoster virus (VZV) and influenza vaccines cannot be accelerated, however.

If one is protecting against hepatitis A with hepatitis A immunoglobulin, Dr. Parker noted that hepatitis A IgG interferes with MMR and VZV. Therefore, MMR and/or VZV vaccines should be given 2 weeks earlier, she said, adding that hepatitis A vaccine and IgG can be given together. Hepatitis A IgG must be repeated every 5 months while the child is in an endemic area.

Dr. Parker urged primary care physicians to consider prevalence of disease in destination nations when reviewing itineraries. Influenza should not be overlooked, she said. It is endemic year-round close to the equator and from March to October in the southern hemisphere. She suggested stockpiling flu vaccine released in October for use through June 30.

Meningococcal vaccine is required for pilgrims making the hajj, Dr. Parker noted. She said it also should be considered, even if off label, for children heading to Africa's “meningitis belt” and other potential risk areas.

Causing 22 million cases a year, Salmonella typhi is a concern throughout the developing world, she said. She advised vaccinating anyone older than 2 years of age who is heading to an endemic area.

Two vaccines are options if typhoid is a risk, Dr. Parker said. The injectable capsular polysaccharide vaccine is approved for children over 2 years and can be given 2 weeks prior to travel. Oral live, attenuated Ty21 a virus vaccine is approved for children older than 6 years but cannot be given if the child is immunodeficient.

Yellow fever vaccine is indicated for travel to endemic areas and required by some countries unless contraindicated. It should not be given to infants younger than 4 months old and is contraindicated in infants 5–9 months of age. Because encephalitis can be a side effect, “you don't want to give it to someone who doesn't need it,” she advised.

Japanese encephalitis is a risk in parts of Asia. Mortality is high, however, with deaths in 5%–30% of those who develop symptoms, according to Dr. Parker.

If mosquito exposure is likely during an extended stay in an endemic area during the endemic season, she recommended vaccination with an inactivated virus. It is approved for persons over 1 year of age. Because severe allergic reactions can occur up to 10 days afterward, she said this vaccine should be given at least 2 weeks in advance of travel.

No drug can prevent malarial infection, Dr. Parker said, but some agents can prevent disease. For pediatric considerations in prophylaxis, she referred physicians to a journal article (Semin. Pediatr. Infect. Dis. 2004;15:137–49).

Whether or not prophylaxis is used, families should try to prevent mosquito bites by making careful use of N,N-diethyl-m-toluamide (DEET), wearing permethrin-treated clothing, and covering exposed skin.

Dogs and sweets pose special risks when traveling with young children who love both. Along with the usual dietary precautions, Dr. Parker warned that frozen desserts may not be pasteurized. Parents should be told to seek care early if a child gets diarrhea. Much of the world has dog rabies, she added, so teaching children not to pet animals is important, albeit difficult. She recommended vaccinating children against rabies before travel to highly endemic areas. But she warned that a vaccinated child would have to be revaccinated if bitten.

“Vaccination is not enough. It just buys time,” Dr. Parker said, noting that postexposure prophylaxis is not available in some countries.

Visits to Families Abroad Pose Risks

Foreign-born families taking young children to meet relatives in their home countries face significantly greater health risks, compared with other travelers, according to Dr. Parker.

The youngsters are often very young; mothers may travel while pregnant; and, sometimes, family members are ill even before they leave on trips timed to family occasions, she said.

These families also stay longer, use less safe local transportation, and have difficulty refusing unsafe food or water in the homes of friends and relatives, Dr. Parker observed. As a result, visitors of friends and relatives are 10 times as likely to get malaria or typhoid as tourists.

Yet, foreign-born parents often do not seek medical advice before these journeys, according to Dr. Parker. Even if they have concerns, many don't seek pretravel advice because of the expense.

Some do not believe their families have to worry about organisms in the communities where they grew up. These travelers often see themselves and their children as “already immune,” which in large part is a myth, especially for their children, she said.

Even if they see a physician, travelers going back home are less likely to follow medical advice than are ecotourists, adventurers, missionaries, or relief workers traveling to developing countries.

Some Travel Health Web Sites

CDC Traveler's Health Web Site

www.cdc.gov/travel/destinat.htm

CDC Yellow Book

http://www.cdc.gov/travel/yb/index.htm

World Health Organization Vaccine Preventable Diseases Monitoring System

(Vaccine schedules listed by country)

www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

WHO Global Health Atlas

(Communicable disease, including rabies)

www.who.int/globalatlas

Pan American Health Organization

www.paho.org

International Association for Medical Assistance to Travelers (IAMAT)

www.iamat.org

U.S. State Department

http://travel.state.gov/travel/travel_1744.html

Source: Dr. Parker

ASPEN, COLO. — Routine vaccinations can be accelerated to protect very young travelers against infectious diseases in developing countries, Sarah K. Parker, M.D., advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“They can be really protected by about 131/2 months of age,” said Dr. Parker of Children's Hospital and a faculty member in pediatric infectious diseases at the University of Colorado Health Sciences Center, Denver.

Dr. Parker also recommended that physicians do a pretravel assessment to identify additional vaccination requirements by endemic conditions in destination countries. The assessment would include consideration of chemoprophylaxis and counseling parents on ways to prevent infectious disease while traveling abroad.

“Infection only causes about 1% of traveler deaths. However, it is a large fraction of what causes illness while traveling,” she said. About 50%–70% of travelers become ill. About 40% of illnesses are diarrhea, which can be more severe and more prolonged in children.

Routine vaccinations can start at 6 weeks of age, she said, outlining an accelerated schedule. Babies can receive four doses of inactivated polio vaccine; three doses of DTaP vaccine, Haemophilus influenzae type b vaccine, and seven-valent pneumococcal polysaccharide vaccine; and two doses of hepatitis B virus vaccine by 14 weeks.

MMR can be given at 6 months, she said, but does not count. If given at 12 months, it can be followed by a booster at 13 months. The accelerated schedule also permits hepatitis A virus vaccine off-label at 12 months.

A family traveling to Africa's “meningitis belt” should use the polysaccharide conjugate vaccine for children older than 11 years, the polysaccharide meningococcal vaccine for children 2–11 years, and consider its use off label in younger children at high risk, she said. The polysaccharide vaccine has been studied at 3 months with a 12-month booster with a rise in titers against meningococcus A, the predominant strain in Africa.

Varicella zoster virus (VZV) and influenza vaccines cannot be accelerated, however.

If one is protecting against hepatitis A with hepatitis A immunoglobulin, Dr. Parker noted that hepatitis A IgG interferes with MMR and VZV. Therefore, MMR and/or VZV vaccines should be given 2 weeks earlier, she said, adding that hepatitis A vaccine and IgG can be given together. Hepatitis A IgG must be repeated every 5 months while the child is in an endemic area.

Dr. Parker urged primary care physicians to consider prevalence of disease in destination nations when reviewing itineraries. Influenza should not be overlooked, she said. It is endemic year-round close to the equator and from March to October in the southern hemisphere. She suggested stockpiling flu vaccine released in October for use through June 30.

Meningococcal vaccine is required for pilgrims making the hajj, Dr. Parker noted. She said it also should be considered, even if off label, for children heading to Africa's “meningitis belt” and other potential risk areas.

Causing 22 million cases a year, Salmonella typhi is a concern throughout the developing world, she said. She advised vaccinating anyone older than 2 years of age who is heading to an endemic area.

Two vaccines are options if typhoid is a risk, Dr. Parker said. The injectable capsular polysaccharide vaccine is approved for children over 2 years and can be given 2 weeks prior to travel. Oral live, attenuated Ty21 a virus vaccine is approved for children older than 6 years but cannot be given if the child is immunodeficient.

Yellow fever vaccine is indicated for travel to endemic areas and required by some countries unless contraindicated. It should not be given to infants younger than 4 months old and is contraindicated in infants 5–9 months of age. Because encephalitis can be a side effect, “you don't want to give it to someone who doesn't need it,” she advised.

Japanese encephalitis is a risk in parts of Asia. Mortality is high, however, with deaths in 5%–30% of those who develop symptoms, according to Dr. Parker.

If mosquito exposure is likely during an extended stay in an endemic area during the endemic season, she recommended vaccination with an inactivated virus. It is approved for persons over 1 year of age. Because severe allergic reactions can occur up to 10 days afterward, she said this vaccine should be given at least 2 weeks in advance of travel.

No drug can prevent malarial infection, Dr. Parker said, but some agents can prevent disease. For pediatric considerations in prophylaxis, she referred physicians to a journal article (Semin. Pediatr. Infect. Dis. 2004;15:137–49).

Whether or not prophylaxis is used, families should try to prevent mosquito bites by making careful use of N,N-diethyl-m-toluamide (DEET), wearing permethrin-treated clothing, and covering exposed skin.

Dogs and sweets pose special risks when traveling with young children who love both. Along with the usual dietary precautions, Dr. Parker warned that frozen desserts may not be pasteurized. Parents should be told to seek care early if a child gets diarrhea. Much of the world has dog rabies, she added, so teaching children not to pet animals is important, albeit difficult. She recommended vaccinating children against rabies before travel to highly endemic areas. But she warned that a vaccinated child would have to be revaccinated if bitten.

“Vaccination is not enough. It just buys time,” Dr. Parker said, noting that postexposure prophylaxis is not available in some countries.

Visits to Families Abroad Pose Risks

Foreign-born families taking young children to meet relatives in their home countries face significantly greater health risks, compared with other travelers, according to Dr. Parker.

The youngsters are often very young; mothers may travel while pregnant; and, sometimes, family members are ill even before they leave on trips timed to family occasions, she said.

These families also stay longer, use less safe local transportation, and have difficulty refusing unsafe food or water in the homes of friends and relatives, Dr. Parker observed. As a result, visitors of friends and relatives are 10 times as likely to get malaria or typhoid as tourists.

Yet, foreign-born parents often do not seek medical advice before these journeys, according to Dr. Parker. Even if they have concerns, many don't seek pretravel advice because of the expense.

Some do not believe their families have to worry about organisms in the communities where they grew up. These travelers often see themselves and their children as “already immune,” which in large part is a myth, especially for their children, she said.

Even if they see a physician, travelers going back home are less likely to follow medical advice than are ecotourists, adventurers, missionaries, or relief workers traveling to developing countries.

Some Travel Health Web Sites

CDC Traveler's Health Web Site

www.cdc.gov/travel/destinat.htm

CDC Yellow Book

http://www.cdc.gov/travel/yb/index.htm

World Health Organization Vaccine Preventable Diseases Monitoring System

(Vaccine schedules listed by country)

www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

WHO Global Health Atlas

(Communicable disease, including rabies)

www.who.int/globalatlas

Pan American Health Organization

www.paho.org

International Association for Medical Assistance to Travelers (IAMAT)

www.iamat.org

U.S. State Department

http://travel.state.gov/travel/travel_1744.html

Source: Dr. Parker

ASPEN, COLO. — Routine vaccinations can be accelerated to protect very young travelers against infectious diseases in developing countries, Sarah K. Parker, M.D., advised at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

“They can be really protected by about 131/2 months of age,” said Dr. Parker of Children's Hospital and a faculty member in pediatric infectious diseases at the University of Colorado Health Sciences Center, Denver.

Dr. Parker also recommended that physicians do a pretravel assessment to identify additional vaccination requirements by endemic conditions in destination countries. The assessment would include consideration of chemoprophylaxis and counseling parents on ways to prevent infectious disease while traveling abroad.

“Infection only causes about 1% of traveler deaths. However, it is a large fraction of what causes illness while traveling,” she said. About 50%–70% of travelers become ill. About 40% of illnesses are diarrhea, which can be more severe and more prolonged in children.

Routine vaccinations can start at 6 weeks of age, she said, outlining an accelerated schedule. Babies can receive four doses of inactivated polio vaccine; three doses of DTaP vaccine, Haemophilus influenzae type b vaccine, and seven-valent pneumococcal polysaccharide vaccine; and two doses of hepatitis B virus vaccine by 14 weeks.

MMR can be given at 6 months, she said, but does not count. If given at 12 months, it can be followed by a booster at 13 months. The accelerated schedule also permits hepatitis A virus vaccine off-label at 12 months.

A family traveling to Africa's “meningitis belt” should use the polysaccharide conjugate vaccine for children older than 11 years, the polysaccharide meningococcal vaccine for children 2–11 years, and consider its use off label in younger children at high risk, she said. The polysaccharide vaccine has been studied at 3 months with a 12-month booster with a rise in titers against meningococcus A, the predominant strain in Africa.

Varicella zoster virus (VZV) and influenza vaccines cannot be accelerated, however.

If one is protecting against hepatitis A with hepatitis A immunoglobulin, Dr. Parker noted that hepatitis A IgG interferes with MMR and VZV. Therefore, MMR and/or VZV vaccines should be given 2 weeks earlier, she said, adding that hepatitis A vaccine and IgG can be given together. Hepatitis A IgG must be repeated every 5 months while the child is in an endemic area.

Dr. Parker urged primary care physicians to consider prevalence of disease in destination nations when reviewing itineraries. Influenza should not be overlooked, she said. It is endemic year-round close to the equator and from March to October in the southern hemisphere. She suggested stockpiling flu vaccine released in October for use through June 30.

Meningococcal vaccine is required for pilgrims making the hajj, Dr. Parker noted. She said it also should be considered, even if off label, for children heading to Africa's “meningitis belt” and other potential risk areas.

Causing 22 million cases a year, Salmonella typhi is a concern throughout the developing world, she said. She advised vaccinating anyone older than 2 years of age who is heading to an endemic area.

Two vaccines are options if typhoid is a risk, Dr. Parker said. The injectable capsular polysaccharide vaccine is approved for children over 2 years and can be given 2 weeks prior to travel. Oral live, attenuated Ty21 a virus vaccine is approved for children older than 6 years but cannot be given if the child is immunodeficient.

Yellow fever vaccine is indicated for travel to endemic areas and required by some countries unless contraindicated. It should not be given to infants younger than 4 months old and is contraindicated in infants 5–9 months of age. Because encephalitis can be a side effect, “you don't want to give it to someone who doesn't need it,” she advised.

Japanese encephalitis is a risk in parts of Asia. Mortality is high, however, with deaths in 5%–30% of those who develop symptoms, according to Dr. Parker.

If mosquito exposure is likely during an extended stay in an endemic area during the endemic season, she recommended vaccination with an inactivated virus. It is approved for persons over 1 year of age. Because severe allergic reactions can occur up to 10 days afterward, she said this vaccine should be given at least 2 weeks in advance of travel.

No drug can prevent malarial infection, Dr. Parker said, but some agents can prevent disease. For pediatric considerations in prophylaxis, she referred physicians to a journal article (Semin. Pediatr. Infect. Dis. 2004;15:137–49).

Whether or not prophylaxis is used, families should try to prevent mosquito bites by making careful use of N,N-diethyl-m-toluamide (DEET), wearing permethrin-treated clothing, and covering exposed skin.

Dogs and sweets pose special risks when traveling with young children who love both. Along with the usual dietary precautions, Dr. Parker warned that frozen desserts may not be pasteurized. Parents should be told to seek care early if a child gets diarrhea. Much of the world has dog rabies, she added, so teaching children not to pet animals is important, albeit difficult. She recommended vaccinating children against rabies before travel to highly endemic areas. But she warned that a vaccinated child would have to be revaccinated if bitten.

“Vaccination is not enough. It just buys time,” Dr. Parker said, noting that postexposure prophylaxis is not available in some countries.

Visits to Families Abroad Pose Risks

Foreign-born families taking young children to meet relatives in their home countries face significantly greater health risks, compared with other travelers, according to Dr. Parker.

The youngsters are often very young; mothers may travel while pregnant; and, sometimes, family members are ill even before they leave on trips timed to family occasions, she said.

These families also stay longer, use less safe local transportation, and have difficulty refusing unsafe food or water in the homes of friends and relatives, Dr. Parker observed. As a result, visitors of friends and relatives are 10 times as likely to get malaria or typhoid as tourists.

Yet, foreign-born parents often do not seek medical advice before these journeys, according to Dr. Parker. Even if they have concerns, many don't seek pretravel advice because of the expense.

Some do not believe their families have to worry about organisms in the communities where they grew up. These travelers often see themselves and their children as “already immune,” which in large part is a myth, especially for their children, she said.

Even if they see a physician, travelers going back home are less likely to follow medical advice than are ecotourists, adventurers, missionaries, or relief workers traveling to developing countries.

Some Travel Health Web Sites

CDC Traveler's Health Web Site

www.cdc.gov/travel/destinat.htm

CDC Yellow Book

http://www.cdc.gov/travel/yb/index.htm

World Health Organization Vaccine Preventable Diseases Monitoring System

(Vaccine schedules listed by country)

www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

WHO Global Health Atlas

(Communicable disease, including rabies)

www.who.int/globalatlas

Pan American Health Organization

www.paho.org

International Association for Medical Assistance to Travelers (IAMAT)

www.iamat.org

U.S. State Department

http://travel.state.gov/travel/travel_1744.html

Source: Dr. Parker