Kate Johnson

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices, the schedule can be viewed at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine has been added as a new recommendation covering persons aged 60 years or more, regardless of prior history of herpes zoster. Contraindications for this vaccine have been specified for pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts under 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts.

The recommendation for varicella vaccine has been extended to include all age groups, including adults, in whom there is no evidence of varicella immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Evidence of varicella immunity is defined as fulfilling any of these criteria:

▸ Documentation of two doses of varicella vaccine at least 4 weeks apart.

▸ Birth in the United States before 1980— not including health care personnel, immunocompromised persons, or pregnant women.

▸ History of varicella infection verified by a health care provider.

▸ History of herpes zoster infection verified by a health care provider.

▸ Laboratory evidence of immunity or disease confirmation.

The recommendations also specify that health care personnel can receive either a trivalent inactivated influenza virus vaccine or a live, attenuated virus vaccine.

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices, the schedule can be viewed at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine has been added as a new recommendation covering persons aged 60 years or more, regardless of prior history of herpes zoster. Contraindications for this vaccine have been specified for pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts under 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts.

The recommendation for varicella vaccine has been extended to include all age groups, including adults, in whom there is no evidence of varicella immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Evidence of varicella immunity is defined as fulfilling any of these criteria:

▸ Documentation of two doses of varicella vaccine at least 4 weeks apart.

▸ Birth in the United States before 1980— not including health care personnel, immunocompromised persons, or pregnant women.

▸ History of varicella infection verified by a health care provider.

▸ History of herpes zoster infection verified by a health care provider.

▸ Laboratory evidence of immunity or disease confirmation.

The recommendations also specify that health care personnel can receive either a trivalent inactivated influenza virus vaccine or a live, attenuated virus vaccine.

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices, the schedule can be viewed at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine has been added as a new recommendation covering persons aged 60 years or more, regardless of prior history of herpes zoster. Contraindications for this vaccine have been specified for pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts under 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts.

The recommendation for varicella vaccine has been extended to include all age groups, including adults, in whom there is no evidence of varicella immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Evidence of varicella immunity is defined as fulfilling any of these criteria:

▸ Documentation of two doses of varicella vaccine at least 4 weeks apart.

▸ Birth in the United States before 1980— not including health care personnel, immunocompromised persons, or pregnant women.

▸ History of varicella infection verified by a health care provider.

▸ History of herpes zoster infection verified by a health care provider.

▸ Laboratory evidence of immunity or disease confirmation.

The recommendations also specify that health care personnel can receive either a trivalent inactivated influenza virus vaccine or a live, attenuated virus vaccine.

Following warnings in Britain and the United States about the cardiac risks of dopamine agonists Parkinson's disease management, the British Society of Endocrinology recommends continuing the agents for the treatment of pituitary disorders, but with caution.

“Dopamine agonists remain the first-line agents for the management of hyperprolactinaemia and a useful adjunct in the management of acromegaly,” noted a statement released Oct. 9 by the society. However, the lowest effective dose, or even withdrawal of dopamine agonists, should be considered when appropriate.

In response to studies showing an increased risk of mitral, tricuspid, and aortic valve regurgitation associated with the dopamine agonist pergolide, the Food and Drug Administration announced the voluntary withdrawal of pergolide products by manufacturers in March. The United Kingdom's regulatory agency imposed restrictions on the use of another dopamine agonist, cabergoline, in treating Parkinson's disease, but did not make reference to pituitary disease, noted the Society of Endocrinology statement.

While endocrine disorders require considerably lower doses of cabergoline compared with Parkinson's disease, endocrine patients are treated for longer durations. “As the published data indicate that the risk of valve disease relates to the cumulative dose, there is need for vigilance in patients with pituitary disease,” it said. The society recommends screening echocardiograms for patients treated for longer durations, or with high doses of cabergoline. “Bromocriptine has not been implicated as a cause of cardiac fibrosis and remains an effective alternative to cabergoline,” it advised.

The society stated its support for a recommendation in the British National Formulary from the Committee on Safety of Medicines. “Before starting treatment with these ergot derivatives it may be appropriate to measure the erythrocyte sedimentation rate and serum creatinine and to obtain a chest x-ray. Patients should be monitored for dyspnoea, persistent cough, chest pain, cardiac failure and abdominal pain or tenderness. If long-term treatment is expected, then lung-function tests may also be helpful.”

To date, there are no reports of cardiac valve fibrosis tied to dopamine agonist treatment of endocrine disorders.

Following warnings in Britain and the United States about the cardiac risks of dopamine agonists Parkinson's disease management, the British Society of Endocrinology recommends continuing the agents for the treatment of pituitary disorders, but with caution.

“Dopamine agonists remain the first-line agents for the management of hyperprolactinaemia and a useful adjunct in the management of acromegaly,” noted a statement released Oct. 9 by the society. However, the lowest effective dose, or even withdrawal of dopamine agonists, should be considered when appropriate.

In response to studies showing an increased risk of mitral, tricuspid, and aortic valve regurgitation associated with the dopamine agonist pergolide, the Food and Drug Administration announced the voluntary withdrawal of pergolide products by manufacturers in March. The United Kingdom's regulatory agency imposed restrictions on the use of another dopamine agonist, cabergoline, in treating Parkinson's disease, but did not make reference to pituitary disease, noted the Society of Endocrinology statement.

While endocrine disorders require considerably lower doses of cabergoline compared with Parkinson's disease, endocrine patients are treated for longer durations. “As the published data indicate that the risk of valve disease relates to the cumulative dose, there is need for vigilance in patients with pituitary disease,” it said. The society recommends screening echocardiograms for patients treated for longer durations, or with high doses of cabergoline. “Bromocriptine has not been implicated as a cause of cardiac fibrosis and remains an effective alternative to cabergoline,” it advised.

The society stated its support for a recommendation in the British National Formulary from the Committee on Safety of Medicines. “Before starting treatment with these ergot derivatives it may be appropriate to measure the erythrocyte sedimentation rate and serum creatinine and to obtain a chest x-ray. Patients should be monitored for dyspnoea, persistent cough, chest pain, cardiac failure and abdominal pain or tenderness. If long-term treatment is expected, then lung-function tests may also be helpful.”

To date, there are no reports of cardiac valve fibrosis tied to dopamine agonist treatment of endocrine disorders.

Following warnings in Britain and the United States about the cardiac risks of dopamine agonists Parkinson's disease management, the British Society of Endocrinology recommends continuing the agents for the treatment of pituitary disorders, but with caution.

“Dopamine agonists remain the first-line agents for the management of hyperprolactinaemia and a useful adjunct in the management of acromegaly,” noted a statement released Oct. 9 by the society. However, the lowest effective dose, or even withdrawal of dopamine agonists, should be considered when appropriate.

In response to studies showing an increased risk of mitral, tricuspid, and aortic valve regurgitation associated with the dopamine agonist pergolide, the Food and Drug Administration announced the voluntary withdrawal of pergolide products by manufacturers in March. The United Kingdom's regulatory agency imposed restrictions on the use of another dopamine agonist, cabergoline, in treating Parkinson's disease, but did not make reference to pituitary disease, noted the Society of Endocrinology statement.

While endocrine disorders require considerably lower doses of cabergoline compared with Parkinson's disease, endocrine patients are treated for longer durations. “As the published data indicate that the risk of valve disease relates to the cumulative dose, there is need for vigilance in patients with pituitary disease,” it said. The society recommends screening echocardiograms for patients treated for longer durations, or with high doses of cabergoline. “Bromocriptine has not been implicated as a cause of cardiac fibrosis and remains an effective alternative to cabergoline,” it advised.

The society stated its support for a recommendation in the British National Formulary from the Committee on Safety of Medicines. “Before starting treatment with these ergot derivatives it may be appropriate to measure the erythrocyte sedimentation rate and serum creatinine and to obtain a chest x-ray. Patients should be monitored for dyspnoea, persistent cough, chest pain, cardiac failure and abdominal pain or tenderness. If long-term treatment is expected, then lung-function tests may also be helpful.”

To date, there are no reports of cardiac valve fibrosis tied to dopamine agonist treatment of endocrine disorders.

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007; 298(15):1772-1778).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial (JAMA 2007;298:1803-4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same in the first two respiratory seasons, with two cases each in the 2003-2004 and 2004-2005 seasons, it increased to five cases in the 2005-2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005-2006,” they wrote.

The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1-4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005-2006 season all recovered fully after treatment with levofloxacin.

Although the American Academy of Pediatrics' recent position statement regarding the use of fluoroquinolones in children did not include AOM, “acute otitis media caused by the 19A strain described in this report would be an appropriate infection to treat with a fluoroquinolone,” wrote the authors.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug.”

But the authors cautioned that “this information is shared with concern that some clinicians and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.”

The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

They suggested that “in the near future” more primary care clinicians may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

“It isn't going to be easy for the rank and file pediatricians to do that,” commented Dr. Ellen R. Wald, professor and chair of the department of pediatrics at the University of Wisconsin, Madison, and chair of the section of infectious diseases on the American Board of Pediatrics.

“What this study highlights is that when you have a clinical failure [with AOM] it's probably important in this era to be able to send the patient somewhere where [tympanocentesis] can be done. Although serotyping is not routinely performed, susceptibility testing would identify an organism that required treatment with fluoroquinolones,” she said.

This is yet another example of why judicious use of all antibiotics, not just fluoroquinolones, is essential, said Dr. Wald.

“We should really reserve antibiotics for situations in which we're highly suspicious that there's a bacterial infection.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome, since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007; 298(15):1772-1778).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial (JAMA 2007;298:1803-4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same in the first two respiratory seasons, with two cases each in the 2003-2004 and 2004-2005 seasons, it increased to five cases in the 2005-2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005-2006,” they wrote.

The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1-4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005-2006 season all recovered fully after treatment with levofloxacin.

Although the American Academy of Pediatrics' recent position statement regarding the use of fluoroquinolones in children did not include AOM, “acute otitis media caused by the 19A strain described in this report would be an appropriate infection to treat with a fluoroquinolone,” wrote the authors.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug.”

But the authors cautioned that “this information is shared with concern that some clinicians and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.”

The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

They suggested that “in the near future” more primary care clinicians may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

“It isn't going to be easy for the rank and file pediatricians to do that,” commented Dr. Ellen R. Wald, professor and chair of the department of pediatrics at the University of Wisconsin, Madison, and chair of the section of infectious diseases on the American Board of Pediatrics.

“What this study highlights is that when you have a clinical failure [with AOM] it's probably important in this era to be able to send the patient somewhere where [tympanocentesis] can be done. Although serotyping is not routinely performed, susceptibility testing would identify an organism that required treatment with fluoroquinolones,” she said.

This is yet another example of why judicious use of all antibiotics, not just fluoroquinolones, is essential, said Dr. Wald.

“We should really reserve antibiotics for situations in which we're highly suspicious that there's a bacterial infection.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome, since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007; 298(15):1772-1778).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial (JAMA 2007;298:1803-4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same in the first two respiratory seasons, with two cases each in the 2003-2004 and 2004-2005 seasons, it increased to five cases in the 2005-2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005-2006,” they wrote.

The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1-4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005-2006 season all recovered fully after treatment with levofloxacin.

Although the American Academy of Pediatrics' recent position statement regarding the use of fluoroquinolones in children did not include AOM, “acute otitis media caused by the 19A strain described in this report would be an appropriate infection to treat with a fluoroquinolone,” wrote the authors.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug.”

But the authors cautioned that “this information is shared with concern that some clinicians and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.”

The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

They suggested that “in the near future” more primary care clinicians may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

“It isn't going to be easy for the rank and file pediatricians to do that,” commented Dr. Ellen R. Wald, professor and chair of the department of pediatrics at the University of Wisconsin, Madison, and chair of the section of infectious diseases on the American Board of Pediatrics.

“What this study highlights is that when you have a clinical failure [with AOM] it's probably important in this era to be able to send the patient somewhere where [tympanocentesis] can be done. Although serotyping is not routinely performed, susceptibility testing would identify an organism that required treatment with fluoroquinolones,” she said.

This is yet another example of why judicious use of all antibiotics, not just fluoroquinolones, is essential, said Dr. Wald.

“We should really reserve antibiotics for situations in which we're highly suspicious that there's a bacterial infection.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome, since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus conventional colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, reported Dr. David H. Kim and colleagues.

CT colonography “may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing the method as “an effective filter” for conventional colonoscopy (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening colonoscopy is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy.

Their study compared results from 3,163 consecutive patients undergoing colonography screening and universal polypectomy with 3,120 consecutive patients undergoing CT colonography followed by a choice of same-day therapeutic screening for all polyps of at least 6 mm or CT surveillance for one or two polyps of 6–9 mm. Within the CT group, a total of 246 patients (7.9%) were referred for therapeutic screening, whereas 158 patients (5.1%) with a total of 193 polyps chose CT surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CT group and 13.4% of the therapeutic screening group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CT group and 3.4% in the therapeutic screening group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the therapeutic group, compared with just 561 in the primary CT group. In addition, there were seven colonic perforations in the therapeutic group (0.3%), four of which required surgical repair. There were no serious complications in the CT group during either the primary examination or subsequent therapeutic screening.

The results suggest that primary CT with selective therapeutic screening also deserves consideration as a preferred screening strategy “because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CT patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

On the basis of previous experience with CT screening, approximately 60% of polyps of 6–9 mm detected by CT would be expected to be adenomatous, and approximately 3% of CT-detected adenomas of 6–9 mm contain advanced histologic findings,” wrote the authors. “Therefore, we estimated that CT surveillance would yield three to four advanced adenomas,” resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with conventional therapeutic screening.

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CT group vs. 37.6% in the therapeutic group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during therapeutic screening, but were ignored in patients undergoing CT. Recommendations released in by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus conventional colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, reported Dr. David H. Kim and colleagues.

CT colonography “may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing the method as “an effective filter” for conventional colonoscopy (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening colonoscopy is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy.

Their study compared results from 3,163 consecutive patients undergoing colonography screening and universal polypectomy with 3,120 consecutive patients undergoing CT colonography followed by a choice of same-day therapeutic screening for all polyps of at least 6 mm or CT surveillance for one or two polyps of 6–9 mm. Within the CT group, a total of 246 patients (7.9%) were referred for therapeutic screening, whereas 158 patients (5.1%) with a total of 193 polyps chose CT surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CT group and 13.4% of the therapeutic screening group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CT group and 3.4% in the therapeutic screening group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the therapeutic group, compared with just 561 in the primary CT group. In addition, there were seven colonic perforations in the therapeutic group (0.3%), four of which required surgical repair. There were no serious complications in the CT group during either the primary examination or subsequent therapeutic screening.

The results suggest that primary CT with selective therapeutic screening also deserves consideration as a preferred screening strategy “because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CT patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

On the basis of previous experience with CT screening, approximately 60% of polyps of 6–9 mm detected by CT would be expected to be adenomatous, and approximately 3% of CT-detected adenomas of 6–9 mm contain advanced histologic findings,” wrote the authors. “Therefore, we estimated that CT surveillance would yield three to four advanced adenomas,” resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with conventional therapeutic screening.

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CT group vs. 37.6% in the therapeutic group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during therapeutic screening, but were ignored in patients undergoing CT. Recommendations released in by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus conventional colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, reported Dr. David H. Kim and colleagues.

CT colonography “may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing the method as “an effective filter” for conventional colonoscopy (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening colonoscopy is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy.

Their study compared results from 3,163 consecutive patients undergoing colonography screening and universal polypectomy with 3,120 consecutive patients undergoing CT colonography followed by a choice of same-day therapeutic screening for all polyps of at least 6 mm or CT surveillance for one or two polyps of 6–9 mm. Within the CT group, a total of 246 patients (7.9%) were referred for therapeutic screening, whereas 158 patients (5.1%) with a total of 193 polyps chose CT surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CT group and 13.4% of the therapeutic screening group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CT group and 3.4% in the therapeutic screening group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the therapeutic group, compared with just 561 in the primary CT group. In addition, there were seven colonic perforations in the therapeutic group (0.3%), four of which required surgical repair. There were no serious complications in the CT group during either the primary examination or subsequent therapeutic screening.

The results suggest that primary CT with selective therapeutic screening also deserves consideration as a preferred screening strategy “because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CT patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

On the basis of previous experience with CT screening, approximately 60% of polyps of 6–9 mm detected by CT would be expected to be adenomatous, and approximately 3% of CT-detected adenomas of 6–9 mm contain advanced histologic findings,” wrote the authors. “Therefore, we estimated that CT surveillance would yield three to four advanced adenomas,” resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with conventional therapeutic screening.

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CT group vs. 37.6% in the therapeutic group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during therapeutic screening, but were ignored in patients undergoing CT. Recommendations released in by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, said Dr. Eriksson. However, there was a 24% rate of recurrence within the 5-year follow-up.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, said Dr. Eriksson. However, there was a 24% rate of recurrence within the 5-year follow-up.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, said Dr. Eriksson. However, there was a 24% rate of recurrence within the 5-year follow-up.

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen, according to the findings of a study.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007;298:1772–8).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial in the same issue of the journal (JAMA 2007;298:1803–4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same, with two cases each in the 2003–2004 and 2004–2005 seasons, it increased to five cases in the 2005–2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005–2006,” they wrote. The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1–4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005–2006 season all recovered fully after treatment with levofloxacin.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug,” according to the authors. But, they cautioned that “this information is shared with concern that some providers and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.” The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

“In the near future” more primary care providers may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

While S. pneumoniae serotype 19A carries direct implications for children's health, its existence and treatment also has important implications for adults, said Dr. Keith Klugman, professor of infectious diseases at Emory University in Atlanta. “Strains that circulate among children are an important source of pneumococcal infections in adults,” he said. The fact that this new strain requires fluoroquinolone treatment in children, poses a potential threat to adults.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen, according to the findings of a study.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007;298:1772–8).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial in the same issue of the journal (JAMA 2007;298:1803–4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same, with two cases each in the 2003–2004 and 2004–2005 seasons, it increased to five cases in the 2005–2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005–2006,” they wrote. The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1–4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005–2006 season all recovered fully after treatment with levofloxacin.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug,” according to the authors. But, they cautioned that “this information is shared with concern that some providers and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.” The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

“In the near future” more primary care providers may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

While S. pneumoniae serotype 19A carries direct implications for children's health, its existence and treatment also has important implications for adults, said Dr. Keith Klugman, professor of infectious diseases at Emory University in Atlanta. “Strains that circulate among children are an important source of pneumococcal infections in adults,” he said. The fact that this new strain requires fluoroquinolone treatment in children, poses a potential threat to adults.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

A strain of Streptococcus pneumoniae that is resistant to all antibiotics approved to treat acute otitis media in children has been identified as an otopathogen, according to the findings of a study.

The multidrug-resistant serotype 19A strain is not included in the pneumococcal 7-valent conjugate vaccine (PCV-7), reported Dr. Michael E. Pichichero and Dr. Janet R. Casey, from the University of Rochester Medical Center and Legacy Pediatrics, a private practice involved in the study (JAMA 2007;298:1772–8).

Children with the serotype 19A strain “represented a small subset of those in our practice, but the results are worrisome, especially since there are no new antibiotics in the pipeline for ear infections in children,” said Dr. Pichichero in a statement.

“While it appears that the overall decrease in invasive pneumococcal disease still outweighs the increase in serotype 19A, it is clear that surveillance needs to continue for this important pathogen, both for strain type and antibiotic resistance,” commented Dr. Elizabeth Bancroft, from the Los Angeles County Department of Public Health, in an editorial in the same issue of the journal (JAMA 2007;298:1803–4).

The prospective study included 212 children from the authors' clinic who underwent tympanocentesis for acute otitis media (AOM) during one of three respiratory seasons: September 2003-June 2004, September 2004-June 2005, and September 2005-June 2006. All children had been previously immunized with the PCV-7 vaccine.

From the tympanocentesis procedures, a pathogen was identified in 162 cases: nontypable Haemophilus influenzae (n = 94); S. pneumoniae (n = 59); and other (n = 9). Serotyping of the 59 S. pneumoniae pathogens revealed 9 that belonged to serotype 19A, which is resistant to all antibiotics approved by the Food and Drug Administration for the treatment of AOM in children.

Infections caused by the serotype 19A strain “continued to produce symptoms and signs of AOM until aggressive therapy was provided—either surgery or levofloxacin, an antibiotic unapproved for children,” the authors noted.

While the incidence was the same, with two cases each in the 2003–2004 and 2004–2005 seasons, it increased to five cases in the 2005–2006 season. None of the first four cases was treated with effective antibiotics “because we did not perform antibiotic susceptibility testing (or serotyping) contemporaneously as we did in 2005–2006,” they wrote. The first four cases were referred to an otolaryngologist for tympanostomy tube insertion, “and all continued with drainage from their tubes for 1–4 weeks despite use of antibiotic otic drops.”

The five cases from the 2005–2006 season all recovered fully after treatment with levofloxacin.

“Our approach has been to use levofloxacin only for children in whom we have performed tympanocentesis and isolated a 19A serotype organism that is susceptible only to that drug,” according to the authors. But, they cautioned that “this information is shared with concern that some providers and the public will interpret this finding as an indication to begin using levofloxacin or other fluoroquinolones in difficult-to-treat cases of AOM, sinusitis, or other pneumococcal infections. This could lead to disastrous results.” The authors suggested that “an expanded pneumococcal conjugate vaccine to include additional serotypes may be needed sooner than previously thought,” noting that U.S. trials are underway of a vaccine containing 13 serotypes, including 19A.

“In the near future” more primary care providers may need to become trained to perform tympanocentesis in order to avoid the excessive use of fluoroquinolones in children.

While S. pneumoniae serotype 19A carries direct implications for children's health, its existence and treatment also has important implications for adults, said Dr. Keith Klugman, professor of infectious diseases at Emory University in Atlanta. “Strains that circulate among children are an important source of pneumococcal infections in adults,” he said. The fact that this new strain requires fluoroquinolone treatment in children, poses a potential threat to adults.

Both Dr. Pichichero and Dr. Carey report that they have received support for otitis media trials from Ortho-McNeil, maker of levofloxacin, and that they have received compensation for consulting, speaking, and conducting clinical trials of antibiotics and vaccines from multiple companies, including Wyeth, which has a 13-valent pneumococcal conjugate vaccine in phase III trials.

The results are worrisome since there are no new antibiotics in the pipeline for ear infections in children. DR. PICHICHERO

Needle fear can complicate many doctor-patient relationships, but in the case of patients with insulin-dependent diabetes, fear of needles can become a serious barrier to compliance.

Studies show that up to one-quarter of people with diabetes have needle anxiety (Diabetes Res. Clin. Pract. 1999;46:239–46), and that extreme needle phobia exists in about 1% of patients (J. Psychsom. Res. 2001;51:665–72).

If these issues are not properly addressed, they can lead to skipped doses and poor glycemic control, according to Dr. Mary Korytkowski, of the division of endocrinology and metabolism at the University of Pittsburgh, and director of its center for diabetes and endocrinology.

“I've had people tell me it takes them an hour to give the shot,” Dr. Korytkowski said in an interview. “They break out in a cold sweat, they just can't face it, and they have to work themselves up to giving it.”

“For someone with diabetes to have needle fear, and then have to take four shots a day, that's a little bit of an overwhelming request,” commented Dr. H. Peter Chase, professor of pediatrics at the University of Colorado, Denver, and clinical director emeritus of the Barbara Davis Center for Childhood Diabetes, Aurora. “I've had kids [who were] ready to go to college, and the parents were still giving the shot because the kids were so scared of it.”

According to Dr. Korytkowski, needle anxiety can arise not only in first-time insulin users, but also in experienced patients in whom the injection routine has become well established.

Although some patients are clearly focused on their fear of pain or injury, others have psychological issues that are more complex. “Sometimes it is an emotional response to going on insulin,” she said. “Now that we have other injectable medications that are not insulin, I find that some people will accept them more readily. There's something specific about the insulin.”

The psychological implications of reaching insulin dependency may not figure as prominently in needle fear among children or adolescents, whose primary concerns focus more on pain—both physical and social, Dr. Chase said in an interview.

“Only about a third of teenagers are currently in the range recommended by the ADA [American Diabetes Association] for good glycemic control,” he said. There are lots of reasons for this, and fear of needles is one of them.

In fact, Dr. Chase's group recently completed a study looking at the effect of reducing needle pain by fitting pediatric diabetes patients (aged 5–7 years) with a subcutaneous injection port (presented at the 2006 ADA annual meeting). EMLA cream was used for placement of the port, which could then stay in place for 3–5 days. Patients' multiple daily needles (mean, 4.5) were then administered through the port's catheter without piercing the skin. After 6 months, compared with 22 patients in both a control group and a second group who received regular dose-reminder alarms, the 17 patients fitted with the injection ports reported a reduction in pain, which was reflected in significantly improved glycemic control. “The injection port improved pain and/or convenience,” he said.

All patients in the study used pen injection devices, which, like insulin pumps, can help alleviate needle anxiety for several reasons. “Some people just don't like to see the needle, or they're not sure how far they should inject,” Dr. Korytkowski explained. “Sometimes with pen devices you don't really see the needle. And it's all a contained system [which controls insertion depth] so patients don't have to manipulate much.” Jet injectors, which use air to drive an insulin dose through the skin without a needle, also are worth considering.

Devices such as pens and pumps also improve the discreetness of injecting, which is helpful for people whose needle anxiety is rooted in embarrassment, Dr. Korytkowski said. “Individuals with diabetes may be particularly conscious of self-injection in public places, as they fear the judgment of others and stigmatization as a 'sick person,' a 'dependent,' or even a 'drug user,'” she wrote in a review on addressing issues of confidence and convenience in insulin delivery (Clin. Ther. 2005;27[suppl. B]:S89–S100).

Although she has never referred a patient for psychological counseling because of needle anxiety per se, she has referred patients because they have a certain “disconnect” with their condition. “That's a different group. They'll do what has to be done, but they're not happy and they don't connect to it somehow. That takes a while to work through,” she said.

Although some patients who are transitioning to insulin may be extremely vocal about their fear of self-injection, patients' needle anxiety may not always be obvious. Physicians should consider this possibility in patients who are not achieving good glycemic control, Dr. Korytkowski said. “If you have just one visit with a person, you may not find much out, but as you get to know these people—and diabetes is a chronic disease, so you usually get to know them—they will eventually tell you.”

This can be facilitated with some pointed questions, she added. “You can ask if they have ever missed a shot, and why. Many people miss a shot occasionally, but if they're under poor control, that might make me pursue it further.”

For patients with type 2 disease who are used to oral medications but are no longer in good glycemic control, the idea of injections may at first seem daunting. “They'll just say flat out, 'I'm not taking insulin.' They are terrified of giving themselves an injection.” However, this is often remedied with a simple practice session in the office, where they self-inject either with insulin (if indicated) or saline, Dr. Korytkowski said.

“For the majority of people, once they've given [themselves] that first injection and seen what's involved, they see it's not as bad as they had thought, and they realize they can do it.”

Both Dr. Korytkowski and Dr. Chase believe there are many layers to needle anxiety—pain and fear sometimes being separate issues, and sometimes occurring with more general phobic or depressive symptoms.

Although addressing this is usually time consuming, and may require additional help from specialists or nurse educators, it can result in improved glycemic control and frequently improves patients' quality of life.

'I've had kids [who were] ready to go to college, and the parents were still giving the shot.' DR. CHASE

Needle fear can complicate many doctor-patient relationships, but in the case of patients with insulin-dependent diabetes, fear of needles can become a serious barrier to compliance.

Studies show that up to one-quarter of people with diabetes have needle anxiety (Diabetes Res. Clin. Pract. 1999;46:239–46), and that extreme needle phobia exists in about 1% of patients (J. Psychsom. Res. 2001;51:665–72).

If these issues are not properly addressed, they can lead to skipped doses and poor glycemic control, according to Dr. Mary Korytkowski, of the division of endocrinology and metabolism at the University of Pittsburgh, and director of its center for diabetes and endocrinology.

“I've had people tell me it takes them an hour to give the shot,” Dr. Korytkowski said in an interview. “They break out in a cold sweat, they just can't face it, and they have to work themselves up to giving it.”

“For someone with diabetes to have needle fear, and then have to take four shots a day, that's a little bit of an overwhelming request,” commented Dr. H. Peter Chase, professor of pediatrics at the University of Colorado, Denver, and clinical director emeritus of the Barbara Davis Center for Childhood Diabetes, Aurora. “I've had kids [who were] ready to go to college, and the parents were still giving the shot because the kids were so scared of it.”

According to Dr. Korytkowski, needle anxiety can arise not only in first-time insulin users, but also in experienced patients in whom the injection routine has become well established.

Although some patients are clearly focused on their fear of pain or injury, others have psychological issues that are more complex. “Sometimes it is an emotional response to going on insulin,” she said. “Now that we have other injectable medications that are not insulin, I find that some people will accept them more readily. There's something specific about the insulin.”

The psychological implications of reaching insulin dependency may not figure as prominently in needle fear among children or adolescents, whose primary concerns focus more on pain—both physical and social, Dr. Chase said in an interview.

“Only about a third of teenagers are currently in the range recommended by the ADA [American Diabetes Association] for good glycemic control,” he said. There are lots of reasons for this, and fear of needles is one of them.

In fact, Dr. Chase's group recently completed a study looking at the effect of reducing needle pain by fitting pediatric diabetes patients (aged 5–7 years) with a subcutaneous injection port (presented at the 2006 ADA annual meeting). EMLA cream was used for placement of the port, which could then stay in place for 3–5 days. Patients' multiple daily needles (mean, 4.5) were then administered through the port's catheter without piercing the skin. After 6 months, compared with 22 patients in both a control group and a second group who received regular dose-reminder alarms, the 17 patients fitted with the injection ports reported a reduction in pain, which was reflected in significantly improved glycemic control. “The injection port improved pain and/or convenience,” he said.

All patients in the study used pen injection devices, which, like insulin pumps, can help alleviate needle anxiety for several reasons. “Some people just don't like to see the needle, or they're not sure how far they should inject,” Dr. Korytkowski explained. “Sometimes with pen devices you don't really see the needle. And it's all a contained system [which controls insertion depth] so patients don't have to manipulate much.” Jet injectors, which use air to drive an insulin dose through the skin without a needle, also are worth considering.

Devices such as pens and pumps also improve the discreetness of injecting, which is helpful for people whose needle anxiety is rooted in embarrassment, Dr. Korytkowski said. “Individuals with diabetes may be particularly conscious of self-injection in public places, as they fear the judgment of others and stigmatization as a 'sick person,' a 'dependent,' or even a 'drug user,'” she wrote in a review on addressing issues of confidence and convenience in insulin delivery (Clin. Ther. 2005;27[suppl. B]:S89–S100).

Although she has never referred a patient for psychological counseling because of needle anxiety per se, she has referred patients because they have a certain “disconnect” with their condition. “That's a different group. They'll do what has to be done, but they're not happy and they don't connect to it somehow. That takes a while to work through,” she said.

Although some patients who are transitioning to insulin may be extremely vocal about their fear of self-injection, patients' needle anxiety may not always be obvious. Physicians should consider this possibility in patients who are not achieving good glycemic control, Dr. Korytkowski said. “If you have just one visit with a person, you may not find much out, but as you get to know these people—and diabetes is a chronic disease, so you usually get to know them—they will eventually tell you.”

This can be facilitated with some pointed questions, she added. “You can ask if they have ever missed a shot, and why. Many people miss a shot occasionally, but if they're under poor control, that might make me pursue it further.”

For patients with type 2 disease who are used to oral medications but are no longer in good glycemic control, the idea of injections may at first seem daunting. “They'll just say flat out, 'I'm not taking insulin.' They are terrified of giving themselves an injection.” However, this is often remedied with a simple practice session in the office, where they self-inject either with insulin (if indicated) or saline, Dr. Korytkowski said.

“For the majority of people, once they've given [themselves] that first injection and seen what's involved, they see it's not as bad as they had thought, and they realize they can do it.”

Both Dr. Korytkowski and Dr. Chase believe there are many layers to needle anxiety—pain and fear sometimes being separate issues, and sometimes occurring with more general phobic or depressive symptoms.

Although addressing this is usually time consuming, and may require additional help from specialists or nurse educators, it can result in improved glycemic control and frequently improves patients' quality of life.

'I've had kids [who were] ready to go to college, and the parents were still giving the shot.' DR. CHASE

Needle fear can complicate many doctor-patient relationships, but in the case of patients with insulin-dependent diabetes, fear of needles can become a serious barrier to compliance.

Studies show that up to one-quarter of people with diabetes have needle anxiety (Diabetes Res. Clin. Pract. 1999;46:239–46), and that extreme needle phobia exists in about 1% of patients (J. Psychsom. Res. 2001;51:665–72).

If these issues are not properly addressed, they can lead to skipped doses and poor glycemic control, according to Dr. Mary Korytkowski, of the division of endocrinology and metabolism at the University of Pittsburgh, and director of its center for diabetes and endocrinology.

“I've had people tell me it takes them an hour to give the shot,” Dr. Korytkowski said in an interview. “They break out in a cold sweat, they just can't face it, and they have to work themselves up to giving it.”

“For someone with diabetes to have needle fear, and then have to take four shots a day, that's a little bit of an overwhelming request,” commented Dr. H. Peter Chase, professor of pediatrics at the University of Colorado, Denver, and clinical director emeritus of the Barbara Davis Center for Childhood Diabetes, Aurora. “I've had kids [who were] ready to go to college, and the parents were still giving the shot because the kids were so scared of it.”

According to Dr. Korytkowski, needle anxiety can arise not only in first-time insulin users, but also in experienced patients in whom the injection routine has become well established.

Although some patients are clearly focused on their fear of pain or injury, others have psychological issues that are more complex. “Sometimes it is an emotional response to going on insulin,” she said. “Now that we have other injectable medications that are not insulin, I find that some people will accept them more readily. There's something specific about the insulin.”

The psychological implications of reaching insulin dependency may not figure as prominently in needle fear among children or adolescents, whose primary concerns focus more on pain—both physical and social, Dr. Chase said in an interview.

“Only about a third of teenagers are currently in the range recommended by the ADA [American Diabetes Association] for good glycemic control,” he said. There are lots of reasons for this, and fear of needles is one of them.

In fact, Dr. Chase's group recently completed a study looking at the effect of reducing needle pain by fitting pediatric diabetes patients (aged 5–7 years) with a subcutaneous injection port (presented at the 2006 ADA annual meeting). EMLA cream was used for placement of the port, which could then stay in place for 3–5 days. Patients' multiple daily needles (mean, 4.5) were then administered through the port's catheter without piercing the skin. After 6 months, compared with 22 patients in both a control group and a second group who received regular dose-reminder alarms, the 17 patients fitted with the injection ports reported a reduction in pain, which was reflected in significantly improved glycemic control. “The injection port improved pain and/or convenience,” he said.

All patients in the study used pen injection devices, which, like insulin pumps, can help alleviate needle anxiety for several reasons. “Some people just don't like to see the needle, or they're not sure how far they should inject,” Dr. Korytkowski explained. “Sometimes with pen devices you don't really see the needle. And it's all a contained system [which controls insertion depth] so patients don't have to manipulate much.” Jet injectors, which use air to drive an insulin dose through the skin without a needle, also are worth considering.

Devices such as pens and pumps also improve the discreetness of injecting, which is helpful for people whose needle anxiety is rooted in embarrassment, Dr. Korytkowski said. “Individuals with diabetes may be particularly conscious of self-injection in public places, as they fear the judgment of others and stigmatization as a 'sick person,' a 'dependent,' or even a 'drug user,'” she wrote in a review on addressing issues of confidence and convenience in insulin delivery (Clin. Ther. 2005;27[suppl. B]:S89–S100).

Although she has never referred a patient for psychological counseling because of needle anxiety per se, she has referred patients because they have a certain “disconnect” with their condition. “That's a different group. They'll do what has to be done, but they're not happy and they don't connect to it somehow. That takes a while to work through,” she said.

Although some patients who are transitioning to insulin may be extremely vocal about their fear of self-injection, patients' needle anxiety may not always be obvious. Physicians should consider this possibility in patients who are not achieving good glycemic control, Dr. Korytkowski said. “If you have just one visit with a person, you may not find much out, but as you get to know these people—and diabetes is a chronic disease, so you usually get to know them—they will eventually tell you.”

This can be facilitated with some pointed questions, she added. “You can ask if they have ever missed a shot, and why. Many people miss a shot occasionally, but if they're under poor control, that might make me pursue it further.”

For patients with type 2 disease who are used to oral medications but are no longer in good glycemic control, the idea of injections may at first seem daunting. “They'll just say flat out, 'I'm not taking insulin.' They are terrified of giving themselves an injection.” However, this is often remedied with a simple practice session in the office, where they self-inject either with insulin (if indicated) or saline, Dr. Korytkowski said.

“For the majority of people, once they've given [themselves] that first injection and seen what's involved, they see it's not as bad as they had thought, and they realize they can do it.”

Both Dr. Korytkowski and Dr. Chase believe there are many layers to needle anxiety—pain and fear sometimes being separate issues, and sometimes occurring with more general phobic or depressive symptoms.

Although addressing this is usually time consuming, and may require additional help from specialists or nurse educators, it can result in improved glycemic control and frequently improves patients' quality of life.

'I've had kids [who were] ready to go to college, and the parents were still giving the shot.' DR. CHASE

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org

Children diagnosed with celiac disease usually experience complete remission once they are started on a gluten-free diet, and thus early diagnosis can be beneficial. But early diagnosis may have adverse effects as well. A large British study has found that a diagnosis of celiac disease in childhood, as opposed to adulthood, is associated with threefold higher mortality–largely due to suicide, accidents, and violence.

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation. “One certainly cannot ignore this report; it's a well-done study,” he said in an interview.

The investigators analyzed data on a cohort of 625 celiac patients and found that those who were diagnosed in childhood (47%) had mortality rates three times higher than would be expected in the general, age-matched population, “with the main cause of the increase being deaths from accidents, suicide, and violence,” reported Dr. Masoud Solaymani-Dodoran and colleagues from the University of Nottingham (England). This increase was not seen in the cohort diagnosed in adulthood (Am. J. Gastroenterol. 2007;102:864-70).

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview. The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Effect of Nonadherence

“Unfortunately [the researchers] had no available data to tell us what percentage of the subjects was on a gluten-free diet,” Dr. Guandalini said in an interview. Nonadherence with the diet has been reported, in other studies, in up to 60% of celiac patients during the rebellious teenage years.

This could explain the increased mortality, he suggested, because in some celiac patients, dietary lapses can have a dramatic effect on the brain. Gluten restriction is recommended, both to relieve the myriad and varied symptoms of celiac disease–ranging from dental to dermatologic to neurologic–and to reduce the potential long-term effects of prolonged exposure, including osteoporosis and malignancies.

“My speculation is that most of these deaths occurred in people who were not following the diet, and this caused the behavioral and psychiatric milieu that would lead to that kind of outcome,” he said.

Finnish authors have suggested that exposure to gluten in adolescents with celiac disease can impair the availability of tryptophan “and the possible consequent serotonergic dysfunction may play a role in vulnerability to depressive disorders” (BMC Psychiatry 2005;5:14-9). They noted that five of nine newly diagnosed, untreated adolescent celiac patients had depressive disorders and abnormal tryptophan levels, all of which improved after gluten was removed from their diets.

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old.

The Impact of Adherence

“We know adherence [to the diet] and depression and anxiety are related,” said Jessica Edwards George, Ph.D., psychologist and researcher at The Celiac Center at Beth Israel Deaconess Medical Center in Boston. But the relationship between adherence and psychological symptoms is not well understood, she said in an interview. Just as poor adherence is linked with psychiatric pathology, so too is good adherence–an aspect highlighted by the British authors.

“The actual process of labeling a child with celiac disease and requiring them to adhere to a gluten-free diet may be, in some way, detrimental,” they wrote. “As treatments go, taking a gluten-free diet must rank as one of the most intrusive for a child–more so than something like, for example, epilepsy or asthma,” coauthor Dr. Richard Logan said in an interview. “We wondered what were the psychological effects on a child of being brought up with a condition whose treatment has such a profound effect on daily life–something I suspect most adult gastroenterologists overlook.”

The psychological research on adults regarding this question leaves little open to debate: “There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. Furthermore, “a child doesn't necessarily have the developmental capacities to cope the way an adult might.”

As a former school psychologist, Dr. Edwards George agreed. “Children report feeling different and embarrassed, left out, and angry,” she wrote in a recent article for the National Association of School Psychologists (NASP Communiquè 2006 June;34:8). “It can be heart-breaking for a child to be unable to eat gluten-containing treats at special occasions, such as birthdays or holidays.”

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years. “The most important thing we think of with adolescents is the social network,” Dr. Jedel said. “If they are not able to eat what their friends eat, all of the shame, the embarrassment, the frustration associated with these ongoing social situations would I'm sure produce a lot of anger, and depression.”

One Italian study which included 39 adolescent patients pointed to the ages between 12 and 17 years as being the most problematic. “That is the period of life in which the individual tends to oppose the adult world in search of an individual personality,” wrote Dr. M. Cinquetti and colleagues from Verona (Italy) University (Pediatr. Med. Chir. 1999;21:279-83). “In this group, the search for an individual personality is disturbed.”

Even after adolescence, such experiences can have lasting effects. In one study of adult patients, a subset of patients who were diagnosed as children remembered situations from their childhood “with intense emotions, even if the events had occurred many years ago” (J. Hum. Nutr. Dietet. 2005;18:171-80).

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, the British authors noted.

“Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

One way to accomplish this is to behave the way they think their healthy peers are behaving, even though their assumption that “everyone” is drinking, or smoking, or doing drugs is often erroneous, he said in an interview. In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, scoliosis, epilepsy, arthritis, and kidney disease. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

Although Dr. Suris' study did not include patients with celiac disease, he said any condition involving food restriction presents limitations to an adolescent's social life. “It is hard to go out for pizza with your friends and not be able to eat it,” he said. “It has been said that the best contribution for diabetic patients after insulin was the introduction of sugar-free beverages, because this allowed them to socialize with their peers without being seen as different. Maybe we should try to do that with other food problems, so that cafeterias or restaurants have options for them,” he said.

Such options are becoming more widely offered, but Dr. Edwards George said children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious.”

In the meantime, she also believes that vigilance is of utmost importance for physicians. “We need to be more aware of mood factors and more proactive about screening and treatment for depression, anxiety, and suicidal ideation.” Included in this careful follow-up should be targeted screening for eating disorders, she said–a practice soon to be adopted at her center–since her research suggests that these disorders may often be missed in this perhaps more vulnerable population.

“We see a lot of people fearful of eating anything at all” at diagnosis, she said. Patients may have a general fear of long-term consequences, such as cancer or osteoporosis, or may be afraid of short-term consequences, such as becoming violently ill after eating a food containing gluten. Patients also become “hyperfocused on food” as a result of constantly reading labels and asking about ingredients, she said.

Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

As awareness about celiac disease continues to grow, experts agree that the current average 11-year gap between symptom onset and diagnosis will shrink, resulting in more diagnoses in childhood and adolescence.

There was also a consensus among all the experts interviewed that, given the recent findings of an increased mortality rate associated with this earlier diagnosis, any attempts to reduce this higher mortality must begin with a better understanding of the unique burdens that childhood diagnosis and treatment may bring.

Get Help With Celiac Disease

Dr. Edwards George recommends these organizations as good resources for patients and families dealing with celiac disease:

PICeliac Disease Foundation

Phone: 213-654-4085

Web site:

www.celiac.org

PICeliac Sprue Association of the United States of America

Phone: 402-558-0600

Web site:

www.csaceliacs.org

PIGluten Intolerance Group

Phone: 253-833-6655

Web site:

www.gluten.net

PINational Foundation for Celiac Awareness

Phone: 215-325-1306

Web site:

www.celiaccentral.org

For performance on inhibition tasks, not much evidence suggests that marijuana accounts for brain abnormalities among teens.

MONTREAL – Teens who report heavy alcohol use have reduced hippocampal volume, compared with their nondrinking peers, but those who combine marijuana with heavy drinking do not show these abnormalities, Susan Tapert, Ph.D., reported at the annual conference of the EEG and Clinical Neuroscience Society.

“It's possible there could be some neuroprotective effect of marijuana against the effects of alcohol,” said Dr. Tapert of the University of California, San Diego, noting that simultaneous marijuana and alcohol use has been shown to reduce blood alcohol levels.

However, another potential explanation is that “there may be competing pathologies that cancel each other out,” she said in an interview. “Microstructural hippocampal changes related to marijuana use may include increased glial proliferation and white matter density, as well as reduced gray matter density,” which might result in “relatively normal hippocampal volumes … despite functional pathology,” she wrote in a recent study (Neurotoxicol. Teratol. 2007;29:141-52). “This is speculative, and spectroscopic, diffusion, and segmentation studies will be needed to verify these impressions,” she stressed.

In the study, which she presented at the meeting, her group used magnetic resonance imaging to compare hippocampal volumes in 16 adolescent alcohol users, 26 marijuana and alcohol users, and 21 abstainers. The subjects were aged 15-18 years, and MRI was performed after at least 2 days of abstinence from all substances.

The smaller hippocampal volume seen in the alcohol users resulted in an abnormal pattern of right-to-left hippocampal asymmetry, compared with both controls and users of marijuana plus alcohol–and this abnormal asymmetry was related to memory function.

“In the nonusing control group, right-to-left hippocampal ratios were linearly related to best performance on verbal learning tasks, with right greater than left ratios linked to the best performances,” Dr. Tapert said. “In contrast, adolescent drinkers and adolescent users of marijuana plus alcohol did not show any relationship between hippocampal asymmetry and learning performance. This could indicate underlying pathology in the substance-using teens, in which hippocampal ratios no longer index encoding ability.”

She went on to speculate that the pathological lack of correspondence between performance and volumes might be attributable to a combination of simultaneous microstructural factors, such as edema, atrophy, altered myelination, and altered synaptic pruning.

Brain volume studies may show little effect of marijuana use, but brain function tests tell another story, Dr. Tapert said. In another recent study by her group, although marijuana-using adolescents who had abstained for 28 days performed similarly to nonusers on an inhibition task, functional MRI showed evidence of more brain processing effort to achieve adequate performance levels in the users (Psychopharmacology [Berl] 2007;194:173-83).

And in another study by her group, 31 marijuana-using adolescents were compared with 34 controls on neuropsychological functioning. Users had slower psychomotor speed and poorer complex attention, verbal learning and memory, and planning and sequencing ability, even after more than 23 days of abstinence (J. Int. Neuropsychol. Soc. 2007;13:807-20).

Dr. Tapert suggested that some brain function abnormalities noted in adolescent marijuana users may not be caused by substance use but could possibly predate it.

“For performance on inhibition tasks, there is not much evidence to suggest that marijuana is accounting for the abnormalities, and there is a suggestion of premorbid differences,” she said. “In contrast, abnormalities in verbal learning and memory do not appear linked to premorbid functioning and may possibly relate specifically to heavy marijuana use during adolescence.”

For performance on inhibition tasks, not much evidence suggests that marijuana accounts for brain abnormalities among teens.

MONTREAL – Teens who report heavy alcohol use have reduced hippocampal volume, compared with their nondrinking peers, but those who combine marijuana with heavy drinking do not show these abnormalities, Susan Tapert, Ph.D., reported at the annual conference of the EEG and Clinical Neuroscience Society.

“It's possible there could be some neuroprotective effect of marijuana against the effects of alcohol,” said Dr. Tapert of the University of California, San Diego, noting that simultaneous marijuana and alcohol use has been shown to reduce blood alcohol levels.

However, another potential explanation is that “there may be competing pathologies that cancel each other out,” she said in an interview. “Microstructural hippocampal changes related to marijuana use may include increased glial proliferation and white matter density, as well as reduced gray matter density,” which might result in “relatively normal hippocampal volumes … despite functional pathology,” she wrote in a recent study (Neurotoxicol. Teratol. 2007;29:141-52). “This is speculative, and spectroscopic, diffusion, and segmentation studies will be needed to verify these impressions,” she stressed.

In the study, which she presented at the meeting, her group used magnetic resonance imaging to compare hippocampal volumes in 16 adolescent alcohol users, 26 marijuana and alcohol users, and 21 abstainers. The subjects were aged 15-18 years, and MRI was performed after at least 2 days of abstinence from all substances.

The smaller hippocampal volume seen in the alcohol users resulted in an abnormal pattern of right-to-left hippocampal asymmetry, compared with both controls and users of marijuana plus alcohol–and this abnormal asymmetry was related to memory function.

“In the nonusing control group, right-to-left hippocampal ratios were linearly related to best performance on verbal learning tasks, with right greater than left ratios linked to the best performances,” Dr. Tapert said. “In contrast, adolescent drinkers and adolescent users of marijuana plus alcohol did not show any relationship between hippocampal asymmetry and learning performance. This could indicate underlying pathology in the substance-using teens, in which hippocampal ratios no longer index encoding ability.”

She went on to speculate that the pathological lack of correspondence between performance and volumes might be attributable to a combination of simultaneous microstructural factors, such as edema, atrophy, altered myelination, and altered synaptic pruning.

Brain volume studies may show little effect of marijuana use, but brain function tests tell another story, Dr. Tapert said. In another recent study by her group, although marijuana-using adolescents who had abstained for 28 days performed similarly to nonusers on an inhibition task, functional MRI showed evidence of more brain processing effort to achieve adequate performance levels in the users (Psychopharmacology [Berl] 2007;194:173-83).

And in another study by her group, 31 marijuana-using adolescents were compared with 34 controls on neuropsychological functioning. Users had slower psychomotor speed and poorer complex attention, verbal learning and memory, and planning and sequencing ability, even after more than 23 days of abstinence (J. Int. Neuropsychol. Soc. 2007;13:807-20).

Dr. Tapert suggested that some brain function abnormalities noted in adolescent marijuana users may not be caused by substance use but could possibly predate it.

“For performance on inhibition tasks, there is not much evidence to suggest that marijuana is accounting for the abnormalities, and there is a suggestion of premorbid differences,” she said. “In contrast, abnormalities in verbal learning and memory do not appear linked to premorbid functioning and may possibly relate specifically to heavy marijuana use during adolescence.”

For performance on inhibition tasks, not much evidence suggests that marijuana accounts for brain abnormalities among teens.

MONTREAL – Teens who report heavy alcohol use have reduced hippocampal volume, compared with their nondrinking peers, but those who combine marijuana with heavy drinking do not show these abnormalities, Susan Tapert, Ph.D., reported at the annual conference of the EEG and Clinical Neuroscience Society.

“It's possible there could be some neuroprotective effect of marijuana against the effects of alcohol,” said Dr. Tapert of the University of California, San Diego, noting that simultaneous marijuana and alcohol use has been shown to reduce blood alcohol levels.

However, another potential explanation is that “there may be competing pathologies that cancel each other out,” she said in an interview. “Microstructural hippocampal changes related to marijuana use may include increased glial proliferation and white matter density, as well as reduced gray matter density,” which might result in “relatively normal hippocampal volumes … despite functional pathology,” she wrote in a recent study (Neurotoxicol. Teratol. 2007;29:141-52). “This is speculative, and spectroscopic, diffusion, and segmentation studies will be needed to verify these impressions,” she stressed.

In the study, which she presented at the meeting, her group used magnetic resonance imaging to compare hippocampal volumes in 16 adolescent alcohol users, 26 marijuana and alcohol users, and 21 abstainers. The subjects were aged 15-18 years, and MRI was performed after at least 2 days of abstinence from all substances.

The smaller hippocampal volume seen in the alcohol users resulted in an abnormal pattern of right-to-left hippocampal asymmetry, compared with both controls and users of marijuana plus alcohol–and this abnormal asymmetry was related to memory function.

“In the nonusing control group, right-to-left hippocampal ratios were linearly related to best performance on verbal learning tasks, with right greater than left ratios linked to the best performances,” Dr. Tapert said. “In contrast, adolescent drinkers and adolescent users of marijuana plus alcohol did not show any relationship between hippocampal asymmetry and learning performance. This could indicate underlying pathology in the substance-using teens, in which hippocampal ratios no longer index encoding ability.”

She went on to speculate that the pathological lack of correspondence between performance and volumes might be attributable to a combination of simultaneous microstructural factors, such as edema, atrophy, altered myelination, and altered synaptic pruning.

Brain volume studies may show little effect of marijuana use, but brain function tests tell another story, Dr. Tapert said. In another recent study by her group, although marijuana-using adolescents who had abstained for 28 days performed similarly to nonusers on an inhibition task, functional MRI showed evidence of more brain processing effort to achieve adequate performance levels in the users (Psychopharmacology [Berl] 2007;194:173-83).

And in another study by her group, 31 marijuana-using adolescents were compared with 34 controls on neuropsychological functioning. Users had slower psychomotor speed and poorer complex attention, verbal learning and memory, and planning and sequencing ability, even after more than 23 days of abstinence (J. Int. Neuropsychol. Soc. 2007;13:807-20).

Dr. Tapert suggested that some brain function abnormalities noted in adolescent marijuana users may not be caused by substance use but could possibly predate it.

“For performance on inhibition tasks, there is not much evidence to suggest that marijuana is accounting for the abnormalities, and there is a suggestion of premorbid differences,” she said. “In contrast, abnormalities in verbal learning and memory do not appear linked to premorbid functioning and may possibly relate specifically to heavy marijuana use during adolescence.”