Kerri Wachter

Neuropsychiatric Systemic Lupus Erythematosus

Imaging can play an important role in ruling out other causes of neuropsychiatric systemic lupus erythematosus (NPSLE), which could be caused by SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition, according to Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor.

“You have to figure out if the [NPSLE] symptoms are related to the lupus,” Dr. Cagnoli said. But “we don't have any specific imaging technique that can tell you that.”

The diagnostic approach also depends in part on the presentation. Are the symptoms focal or acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment/surgery. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” Dr. Cagnoli said. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects,” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals,” she said.

These lesions are not specific to NPSLE. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization, similar to multiple sclerosis. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. MS lesions tend to be bigger, to coalesce, and to progress quickly.

However, imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Functional MRI techniques such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI) are beginning to reveal which patients have functional abnormalities.

When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” Dr. Cagnoli said.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

She and several colleagues are currently enrolling patients in a pilot study to evaluate whether MR spectroscopy, MR perfusion imaging, and MR DTI can detect alterations in brain function distinctive for NPSLE and compare the findings with those found in an existing cohort of 20 normal, healthy controls.

MRI shows NPSLE lesions with fluid attenuated inversion recovery (FLAIR), T2-weighted, and T1-weighted, gadolinium contrast sequences. Courtesy Dr. Pia Maly-Sundgren

Neuropsychiatric Systemic Lupus Erythematosus

Imaging can play an important role in ruling out other causes of neuropsychiatric systemic lupus erythematosus (NPSLE), which could be caused by SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition, according to Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor.

“You have to figure out if the [NPSLE] symptoms are related to the lupus,” Dr. Cagnoli said. But “we don't have any specific imaging technique that can tell you that.”

The diagnostic approach also depends in part on the presentation. Are the symptoms focal or acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment/surgery. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” Dr. Cagnoli said. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects,” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals,” she said.

These lesions are not specific to NPSLE. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization, similar to multiple sclerosis. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. MS lesions tend to be bigger, to coalesce, and to progress quickly.

However, imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Functional MRI techniques such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI) are beginning to reveal which patients have functional abnormalities.

When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” Dr. Cagnoli said.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

She and several colleagues are currently enrolling patients in a pilot study to evaluate whether MR spectroscopy, MR perfusion imaging, and MR DTI can detect alterations in brain function distinctive for NPSLE and compare the findings with those found in an existing cohort of 20 normal, healthy controls.

MRI shows NPSLE lesions with fluid attenuated inversion recovery (FLAIR), T2-weighted, and T1-weighted, gadolinium contrast sequences. Courtesy Dr. Pia Maly-Sundgren

Neuropsychiatric Systemic Lupus Erythematosus

Imaging can play an important role in ruling out other causes of neuropsychiatric systemic lupus erythematosus (NPSLE), which could be caused by SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition, according to Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor.

“You have to figure out if the [NPSLE] symptoms are related to the lupus,” Dr. Cagnoli said. But “we don't have any specific imaging technique that can tell you that.”

The diagnostic approach also depends in part on the presentation. Are the symptoms focal or acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment/surgery. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” Dr. Cagnoli said. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects,” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals,” she said.

These lesions are not specific to NPSLE. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization, similar to multiple sclerosis. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. MS lesions tend to be bigger, to coalesce, and to progress quickly.

However, imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Functional MRI techniques such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI) are beginning to reveal which patients have functional abnormalities.

When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” Dr. Cagnoli said.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

She and several colleagues are currently enrolling patients in a pilot study to evaluate whether MR spectroscopy, MR perfusion imaging, and MR DTI can detect alterations in brain function distinctive for NPSLE and compare the findings with those found in an existing cohort of 20 normal, healthy controls.

MRI shows NPSLE lesions with fluid attenuated inversion recovery (FLAIR), T2-weighted, and T1-weighted, gadolinium contrast sequences. Courtesy Dr. Pia Maly-Sundgren

Neuropsychiatric systemic lupus erythematosus (NPSLE) is a diagnostic challenge, requiring both rheumatologic and neurologic assessments. Diagnosis is complicated by the number of forms the disorder can take. The American College of Rheumatology has described case definitions and diagnostic criteria for 19 central/peripheral nervous system syndromes observed in SLE (Arthritis Rheum. 1999;42:599–608). Diagnosis relies on a combination of clinical assessment, laboratory tests, neuropsychological evaluation, and imaging.

“The problem with neuropsychiatric systemic lupus erythematosus in general is that you have to figure out if the symptoms are related to the lupus,” said Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor. “We don't have any specific imaging technique that can tell you that.” An important element of diagnosis is ruling out other causes of the symptoms: SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition. Imaging can play an important role in ruling out other causes.

The diagnostic approach also depends in part on the presentation. Are the symptoms focal/acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment or surgery. “The CT scan will reveal the most obvious abnormalities,” said Dr. Cagnoli. In addition, CT has the advantages of ready availability—CT equipment is in almost every emergency department—and of being quick to perform. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” said Dr. Cagnoli. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals. Their presence arouses suspicion, but you cannot be certain whether they are related to lupus,” she said.

However, these lesions are not specific to NPSLE. It's theorized that “one of the mechanisms in lupus is demyelinization, which is the same type of lesion in multiple sclerosis,” Dr. Cagnoli noted. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. There are some more specific findings for MS: The lesions tend to be bigger, to coalesce, and to progress quickly.

“Still, we find ourselves with the neurologists going back and forth many, many times—is it SLE or MS?” Imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Researchers are starting to use more functional MRI techniques, such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI). “What we are trying to determine with those techniques is which patients really have functional abnormalities that the structural MRI is not showing us.”

Researchers are seeing important differences with these techniques, particularly with spectroscopy and DTI. When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” Dr. Cagnoli said.

The researchers also hope that imaging will shed more light on the underlying mechanism of neuropsychiatric lupus.

For now, though, imaging is only one part of the multipronged diagnostic approach to NPSLE.

NPSLE lesions can be seen on MRI with fluid attenuated inversion recovery (FLAIR), as well as on T2-weighted MRI and T1 MRI with gadolinium contrast. Image courtesy Dr. Pia Maly-Sundgren

NPSLE hyperintense white matter lesions are seen in more detail above. Image courtesy Dr. Patricia C. Cagnoli

Neuropsychiatric systemic lupus erythematosus (NPSLE) is a diagnostic challenge, requiring both rheumatologic and neurologic assessments. Diagnosis is complicated by the number of forms the disorder can take. The American College of Rheumatology has described case definitions and diagnostic criteria for 19 central/peripheral nervous system syndromes observed in SLE (Arthritis Rheum. 1999;42:599–608). Diagnosis relies on a combination of clinical assessment, laboratory tests, neuropsychological evaluation, and imaging.

“The problem with neuropsychiatric systemic lupus erythematosus in general is that you have to figure out if the symptoms are related to the lupus,” said Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor. “We don't have any specific imaging technique that can tell you that.” An important element of diagnosis is ruling out other causes of the symptoms: SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition. Imaging can play an important role in ruling out other causes.

The diagnostic approach also depends in part on the presentation. Are the symptoms focal/acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment or surgery. “The CT scan will reveal the most obvious abnormalities,” said Dr. Cagnoli. In addition, CT has the advantages of ready availability—CT equipment is in almost every emergency department—and of being quick to perform. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” said Dr. Cagnoli. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals. Their presence arouses suspicion, but you cannot be certain whether they are related to lupus,” she said.

However, these lesions are not specific to NPSLE. It's theorized that “one of the mechanisms in lupus is demyelinization, which is the same type of lesion in multiple sclerosis,” Dr. Cagnoli noted. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. There are some more specific findings for MS: The lesions tend to be bigger, to coalesce, and to progress quickly.

“Still, we find ourselves with the neurologists going back and forth many, many times—is it SLE or MS?” Imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Researchers are starting to use more functional MRI techniques, such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI). “What we are trying to determine with those techniques is which patients really have functional abnormalities that the structural MRI is not showing us.”

Researchers are seeing important differences with these techniques, particularly with spectroscopy and DTI. When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” Dr. Cagnoli said.

The researchers also hope that imaging will shed more light on the underlying mechanism of neuropsychiatric lupus.

For now, though, imaging is only one part of the multipronged diagnostic approach to NPSLE.

NPSLE lesions can be seen on MRI with fluid attenuated inversion recovery (FLAIR), as well as on T2-weighted MRI and T1 MRI with gadolinium contrast. Image courtesy Dr. Pia Maly-Sundgren

NPSLE hyperintense white matter lesions are seen in more detail above. Image courtesy Dr. Patricia C. Cagnoli

Neuropsychiatric systemic lupus erythematosus (NPSLE) is a diagnostic challenge, requiring both rheumatologic and neurologic assessments. Diagnosis is complicated by the number of forms the disorder can take. The American College of Rheumatology has described case definitions and diagnostic criteria for 19 central/peripheral nervous system syndromes observed in SLE (Arthritis Rheum. 1999;42:599–608). Diagnosis relies on a combination of clinical assessment, laboratory tests, neuropsychological evaluation, and imaging.

“The problem with neuropsychiatric systemic lupus erythematosus in general is that you have to figure out if the symptoms are related to the lupus,” said Dr. Patricia C. Cagnoli, a rheumatologist at the University of Michigan in Ann Arbor. “We don't have any specific imaging technique that can tell you that.” An important element of diagnosis is ruling out other causes of the symptoms: SLE-mediated organ dysfunction, infection, medication side effects, metabolic abnormalities, or an unrelated condition. Imaging can play an important role in ruling out other causes.

The diagnostic approach also depends in part on the presentation. Are the symptoms focal/acute or more diffuse? For example, in the case of acute symptoms, CT can help rule out ischemic strokes, large tumors, and massive bleeds—the most acute and urgent conditions that would require immediate treatment or surgery. “The CT scan will reveal the most obvious abnormalities,” said Dr. Cagnoli. In addition, CT has the advantages of ready availability—CT equipment is in almost every emergency department—and of being quick to perform. If a patient has more diffuse symptoms, infection should be ruled out first with a lumbar puncture in addition to imaging.

“MRI is probably the cornerstone imaging technique to use in the diagnosis of neuropsychiatric lupus,” said Dr. Cagnoli. Multiple imaging sequences and intravenous administration of contrast are employed to accurately delineate abnormal areas in the brain. “More often than not, MRI will reveal several lesions that were not detected by CT scanning.” These areas of new injury are likely capable of responding to treatment and healing in ways that cannot be seen by CT.

MRI also frequently identifies small bright spots in the subcortical white matter that are of uncertain significance and are sometimes referred to as “unidentified bright objects” or UBOs.

“Most of the patients with neuropsychiatric lupus will have these hyperintense white matter lesions, but so do apparently normal individuals. Their presence arouses suspicion, but you cannot be certain whether they are related to lupus,” she said.

However, these lesions are not specific to NPSLE. It's theorized that “one of the mechanisms in lupus is demyelinization, which is the same type of lesion in multiple sclerosis,” Dr. Cagnoli noted. It's not uncommon for patients to have small white-matter lesions on MRI that are considered to be areas of possible demyelinization. In fact, patients are often referred to Dr. Cagnoli's group to help determine if patients have MS or lupus with CNS involvement. There are some more specific findings for MS: The lesions tend to be bigger, to coalesce, and to progress quickly.

“Still, we find ourselves with the neurologists going back and forth many, many times—is it SLE or MS?” Imaging is only part of the picture. “It's the rest of your physical assessment, your clinical impression, your laboratory evaluation that will tell you, in the end, what it is,” she said.

Researchers are starting to use more functional MRI techniques, such as MR spectroscopy, diffusion-weighted imaging, and diffusion tensor imaging (DTI). “What we are trying to determine with those techniques is which patients really have functional abnormalities that the structural MRI is not showing us.”

Researchers are seeing important differences with these techniques, particularly with spectroscopy and DTI. When comparing structural and functional MRI, “you have a normal conventional MRI and you see already evidence of neuronal loss or brain injury in the functional MRI,” said Dr. Cagnoli, who is also the associate director of the Michigan Lupus Program.

The researchers hope to use these techniques to identify patients with preclinical NPSLE-type lesions, in order to begin treatment as early as possible. “Eventually, our hope is that we might be able to treat these patients sooner rather than later,” she said. “One of the problems we have with [NPSLE] is trying to identify those patients” who require earlier and more aggressive treatment, “as opposed to those patients who can benefit from a more conservative approach.”

NPSLE requires treatment not just for the neuropsychiatric symptoms, with antipsychotics for psychosis as an example, but also for the underlying SLE, with immunosuppressants and high doses of corticosteroids. “So you treat the symptom—psychosis is the symptom in this case—but also the underlying mechanism, which is the lupus,” Dr. Cagnoli said.

The researchers also hope that imaging will shed more light on the underlying mechanism of neuropsychiatric lupus.

For now, though, imaging is only one part of the multipronged diagnostic approach to NPSLE.

NPSLE lesions can be seen on MRI with fluid attenuated inversion recovery (FLAIR), as well as on T2-weighted MRI and T1 MRI with gadolinium contrast. Image courtesy Dr. Pia Maly-Sundgren

NPSLE hyperintense white matter lesions are seen in more detail above. Image courtesy Dr. Patricia C. Cagnoli

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed of the division of emergency medicine at the hospital.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact only 46% of STI-positive patients within 7 days and 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview. However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 patients (28%) were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners. A total of 11 patients (9%) were untreated and were unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to make the STI reporting system in the pediatric emergency department better. The results will serve as the baseline data that will be used to determine the efficacy of interventions aimed at improving follow-up.

The researchers are looking into “alternative ways to better contact these patients,” Dr. Reed said, and are in the process of performing experiments to determine what interventions or combinations of interventions will best improve the contact rate. These include “providing a cell phone for the nurse practitioner who makes calls so she has better accessibility when these patients call back at nontraditional times.”

The investigators also have developed a card to be handed out to each patient when she undergoes a pelvic exam. The card provides a phone number to reach the nurse practitioner to obtain culture results. “Lastly, we are encouraging nurses and physicians to obtain a confidential number at the time of the exam, since the number given in registration is often a nonworking one,” said Dr. Reed.

The study was supported by a Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Diseases.

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed of the division of emergency medicine at the hospital.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact only 46% of STI-positive patients within 7 days and 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview. However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 patients (28%) were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners. A total of 11 patients (9%) were untreated and were unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to make the STI reporting system in the pediatric emergency department better. The results will serve as the baseline data that will be used to determine the efficacy of interventions aimed at improving follow-up.

The researchers are looking into “alternative ways to better contact these patients,” Dr. Reed said, and are in the process of performing experiments to determine what interventions or combinations of interventions will best improve the contact rate. These include “providing a cell phone for the nurse practitioner who makes calls so she has better accessibility when these patients call back at nontraditional times.”

The investigators also have developed a card to be handed out to each patient when she undergoes a pelvic exam. The card provides a phone number to reach the nurse practitioner to obtain culture results. “Lastly, we are encouraging nurses and physicians to obtain a confidential number at the time of the exam, since the number given in registration is often a nonworking one,” said Dr. Reed.

The study was supported by a Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Diseases.

BALTIMORE — Empiric treatment for sexually transmitted infections among adolescent girls presenting to a pediatric emergency department is high, but many patients are unreachable for follow-up and some remain unaware that they are infected, according to a 3-month baseline study.

In all, 120 young women aged 14–21 years who were seen at the Cincinnati Children's Hospital pediatric emergency department (PED) tested positive for Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis between July 1 and Sept. 23, 2008, reported Dr. Jennifer Reed of the division of emergency medicine at the hospital.

More than two-thirds of adolescents (69%) who tested positive for sexually transmitted infections (STIs) were treated empirically in the PED. The researchers were able to contact only 46% of STI-positive patients within 7 days and 60% within 30 days, according to data presented as a poster at the annual meeting of the Pediatric Academic Societies.

“The most prevalent reasons for the unreachable patients included phones being disconnected, no answer, and full voice mailboxes,” Dr. Reed said in an interview. However, she noted that these data have not been analyzed yet.

The researchers tracked adolescent patients who tested positive for any STI. The usual clinical protocol involved contacting only those patients who tested positive for an STI but who were not treated empirically in the PED.

During the study period, a nurse practitioner attempted to contact all patients who tested positive for an STI, as soon as test results were available, regardless of documentation of PED treatment. Patients contacted at home were notified of their results and offered treatment if needed.

After three unsuccessful phone attempts to contact the patient, a registered letter was sent to the patient with the STI test results and a request to return to the PED. Those without treatment and no telephone contact or follow-up in the PED were classified as lost to follow-up.

The researchers recorded the date of contact and calculated the proportion of patients successfully contacted, the mean and median days to treatment/notification, and the proportions notified within 7 days and within 30 days.

For the 36 patients untreated at the initial PED visit but who tested positive and were successfully contacted, the median number of days to treatment was 8. In all, 9% of girls were lost to follow-up.

A total of 33 patients (28%) were empirically treated for STIs but remained unaware of their infections, putting their partners at risk and themselves at risk for reinfection from positive untreated partners. A total of 11 patients (9%) were untreated and were unaware of their infections, putting themselves at risk for complications from STIs, as well as for spreading infection.

This study is phase I of a quality improvement project designed to make the STI reporting system in the pediatric emergency department better. The results will serve as the baseline data that will be used to determine the efficacy of interventions aimed at improving follow-up.

The researchers are looking into “alternative ways to better contact these patients,” Dr. Reed said, and are in the process of performing experiments to determine what interventions or combinations of interventions will best improve the contact rate. These include “providing a cell phone for the nurse practitioner who makes calls so she has better accessibility when these patients call back at nontraditional times.”

The investigators also have developed a card to be handed out to each patient when she undergoes a pelvic exam. The card provides a phone number to reach the nurse practitioner to obtain culture results. “Lastly, we are encouraging nurses and physicians to obtain a confidential number at the time of the exam, since the number given in registration is often a nonworking one,” said Dr. Reed.

The study was supported by a Cincinnati Hospital Research Foundation Outcomes award, as well as a K23 award from the National Institute of Allergy and Infectious Diseases.

BALTIMORE — Three-quarters of pediatric practices lose money on vaccinations, based on a small study of 34 Georgia practices.

For the study, the researchers stratified the practices by percentage of patients on the federal Vaccines for Children (VFC) program. “Only about 25% of practices receive a positive net return from vaccinating children—the higher the number of VFC patients, the higher the net loss,” said Margaret Coleman, Ph.D., a health economist with the Centers for Disease Control and Prevention and the lead investigator.

The researchers surveyed Georgia pediatricians from three organizations, one of which was the Georgia chapter of the American Academy of Pediatrics. A total of 34 practices provided enough information to be included in the analysis, which was presented at the annual meeting of the Pediatric Academic Societies.

Any child who was on Medicaid or who was uninsured was eligible for VFC and was considered a public payer. Practices received vaccines for these patients free of charge.

Total costs included practice costs, vaccine costs, labor, and overhead. Private reimbursement included administration and vaccine; public reimbursement included only administration.

The average value of the number of doses reported on hand at the practice was $133,644, and the average value of the combination of doses on hand and on order was $274,644.

The median values were $58,107 and $123,500, respectively.

Almost all of the practices ordered vaccines on a monthly basis. However, more expensive vaccines (such as human papillomavirus, or HPV) usually were ordered on a bimonthly basis. “For a small business, this is a lot of cash to be tied up,” said Dr. Coleman.

The researchers found that for children on VFC, practices lost $17 if the child showed up for only one dose.

If the child received five doses, the practice lost almost $12 per child.

“Across the board—private or public pay—it's a loss if a child shows up for just one vaccine dose,” she said.

“The bottom line is that the practices that fall into the 0%–10% [VFC-eligible children] group earn a small return on vaccination when weighted between private-pay and public-pay patients. For all other practices, the losses for VFC-eligible children outweigh the gains from the private-pay patients,” Dr. Coleman said.

In addition, the researchers found that the greater the number of VFC-eligible patients seen in a practice, the lower the pediatrician income. The number of VFC-eligible patients in a practice was directly related to the time spent counseling patients/parents. (See table.)

The practices with 0%–10% of patients being VFC eligible hired more than half of the registered nurses in the entire sample.

Dr. Coleman said it's possible that RNs in these practices may take on more of the vaccine counseling, freeing up physicians for other tasks.

Dr. Coleman reported that she had no conflicts of interest relevant to this study.

ELSEVIER GLOBAL MEDICAL NEWS

BALTIMORE — Three-quarters of pediatric practices lose money on vaccinations, based on a small study of 34 Georgia practices.

For the study, the researchers stratified the practices by percentage of patients on the federal Vaccines for Children (VFC) program. “Only about 25% of practices receive a positive net return from vaccinating children—the higher the number of VFC patients, the higher the net loss,” said Margaret Coleman, Ph.D., a health economist with the Centers for Disease Control and Prevention and the lead investigator.

The researchers surveyed Georgia pediatricians from three organizations, one of which was the Georgia chapter of the American Academy of Pediatrics. A total of 34 practices provided enough information to be included in the analysis, which was presented at the annual meeting of the Pediatric Academic Societies.

Any child who was on Medicaid or who was uninsured was eligible for VFC and was considered a public payer. Practices received vaccines for these patients free of charge.

Total costs included practice costs, vaccine costs, labor, and overhead. Private reimbursement included administration and vaccine; public reimbursement included only administration.

The average value of the number of doses reported on hand at the practice was $133,644, and the average value of the combination of doses on hand and on order was $274,644.

The median values were $58,107 and $123,500, respectively.

Almost all of the practices ordered vaccines on a monthly basis. However, more expensive vaccines (such as human papillomavirus, or HPV) usually were ordered on a bimonthly basis. “For a small business, this is a lot of cash to be tied up,” said Dr. Coleman.

The researchers found that for children on VFC, practices lost $17 if the child showed up for only one dose.

If the child received five doses, the practice lost almost $12 per child.

“Across the board—private or public pay—it's a loss if a child shows up for just one vaccine dose,” she said.

“The bottom line is that the practices that fall into the 0%–10% [VFC-eligible children] group earn a small return on vaccination when weighted between private-pay and public-pay patients. For all other practices, the losses for VFC-eligible children outweigh the gains from the private-pay patients,” Dr. Coleman said.

In addition, the researchers found that the greater the number of VFC-eligible patients seen in a practice, the lower the pediatrician income. The number of VFC-eligible patients in a practice was directly related to the time spent counseling patients/parents. (See table.)

The practices with 0%–10% of patients being VFC eligible hired more than half of the registered nurses in the entire sample.

Dr. Coleman said it's possible that RNs in these practices may take on more of the vaccine counseling, freeing up physicians for other tasks.

Dr. Coleman reported that she had no conflicts of interest relevant to this study.

ELSEVIER GLOBAL MEDICAL NEWS

BALTIMORE — Three-quarters of pediatric practices lose money on vaccinations, based on a small study of 34 Georgia practices.

For the study, the researchers stratified the practices by percentage of patients on the federal Vaccines for Children (VFC) program. “Only about 25% of practices receive a positive net return from vaccinating children—the higher the number of VFC patients, the higher the net loss,” said Margaret Coleman, Ph.D., a health economist with the Centers for Disease Control and Prevention and the lead investigator.

The researchers surveyed Georgia pediatricians from three organizations, one of which was the Georgia chapter of the American Academy of Pediatrics. A total of 34 practices provided enough information to be included in the analysis, which was presented at the annual meeting of the Pediatric Academic Societies.

Any child who was on Medicaid or who was uninsured was eligible for VFC and was considered a public payer. Practices received vaccines for these patients free of charge.

Total costs included practice costs, vaccine costs, labor, and overhead. Private reimbursement included administration and vaccine; public reimbursement included only administration.

The average value of the number of doses reported on hand at the practice was $133,644, and the average value of the combination of doses on hand and on order was $274,644.

The median values were $58,107 and $123,500, respectively.

Almost all of the practices ordered vaccines on a monthly basis. However, more expensive vaccines (such as human papillomavirus, or HPV) usually were ordered on a bimonthly basis. “For a small business, this is a lot of cash to be tied up,” said Dr. Coleman.

The researchers found that for children on VFC, practices lost $17 if the child showed up for only one dose.

If the child received five doses, the practice lost almost $12 per child.

“Across the board—private or public pay—it's a loss if a child shows up for just one vaccine dose,” she said.

“The bottom line is that the practices that fall into the 0%–10% [VFC-eligible children] group earn a small return on vaccination when weighted between private-pay and public-pay patients. For all other practices, the losses for VFC-eligible children outweigh the gains from the private-pay patients,” Dr. Coleman said.

In addition, the researchers found that the greater the number of VFC-eligible patients seen in a practice, the lower the pediatrician income. The number of VFC-eligible patients in a practice was directly related to the time spent counseling patients/parents. (See table.)

The practices with 0%–10% of patients being VFC eligible hired more than half of the registered nurses in the entire sample.

Dr. Coleman said it's possible that RNs in these practices may take on more of the vaccine counseling, freeing up physicians for other tasks.

Dr. Coleman reported that she had no conflicts of interest relevant to this study.

ELSEVIER GLOBAL MEDICAL NEWS

BALTIMORE — School-based influenza vaccination programs can improve the vaccination rate for school-aged children, but getting tweens and teens to participate can be hard, based on a study of school districts in central Texas.

“Expansion of the school-based immunization trial from elementary to middle and high schools improved influenza immunization coverage in school-aged children to 40%,” Dr. Manjusha Gaglani said at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases. This compares with 30% coverage achieved with community-based vaccinations.

On average, influenza immunization coverage was 48%, 28%, and 22% for 26 elementary, 10 middle, and 8 high schools (public), respectively, in the 2007–2008 school year. Average coverage was 52% for parochial schools, 34% for home-schooled children, and 10% for public schools (K-12). The community-based influenza immunization field trial achieved influenza vaccine coverage of 15%–30% of school-aged children between 1998 and 2006. In 2007, a school-based trial was initiated in local elementary schools. The trial was expanded to middle and high schools during the 2008–2009 school year to increase influenza immunization coverage in school-aged children.

Middle and high school students had lower rates of vaccination coverage than elementary children, even though information packets were mailed directly to parents instead of having students take them home, as elementary school students did, said Dr. Gaglani, a pediatric infectious diseases specialist at the Scott and White ambulatory pediatric clinic in Temple, Tex.

The information packets included a letter to parents, a brochure on the program, an influenza vaccine permission form, an assent script for children, an optional nonparticipation form, information about live and inactivated influenza vaccines, and privacy authorization forms. Parents were asked to call with questions and could choose to be present for the immunization either at school or a pediatric clinic. Parents could state a preference for inactivated influenza vaccine and were asked to schedule second doses for eligible children at the Scott and White pediatric clinic.

Approximately 2–4 weeks before the scheduled influenza vaccination day, informed consent and assent were obtained from the parent and capable children 7 years of age or older. Influenza vaccine permission forms containing children's demographic and health information were completed, signed, and dated by the parent and child, and collected by teachers and/or school nurses. School staff organized student flow, and research staff triaged students for live or inactivated influenza vaccine based on the child's health information. Research, public health, and school nurses and investigators administered the vaccines during school hours. Vaccinated students were given a “Guide to Study Participants” and a 6-week health report postcard. Children also were offered “flu fighter” stickers.

The enhanced program involved health care entities and independent school districts. In the program's second year (2008–2009), children aged 4–18 years were enrolled from 45 intervention-area schools—7 public school districts and 5 parochial schools. Home-schooled children also were included.

In all, approximately 22,914 information packets were sent to students. Between Sept. 22 and Dec. 18, 2008, immunization day was conducted at 48 schools, 2 days each at two high schools, and at a church for home-schooled students. Students also were enrolled at the pediatric clinic during six weekend and nine evening clinics, and at one community event. Based on the preliminary results, live nasal spray influenza vaccine was administered to 77% of a total of 9,007 students enrolled in the program.

An additional 588 students and 60 students were immunized at the pediatric clinic and community event, respectively. In addition, 1,878 school staff were vaccinated (67% received the trivalent inactive vaccine). Of the 652 students who returned nonparticipation forms, 91 students reported receiving the influenza vaccine. Another 267 said they would receive the influenza vaccine from their physician.

Dr. Gaglani reported that she has received grants from MedImmune Inc., Sanofi Pasteur Inc., GlaxoSmithKline, and Novartis, and that she is a consultant/speaker for MedImmune and Sanofi Pasteur. In addition, Sanofi Pasteur supplied the vaccine used in the study.

BALTIMORE — School-based influenza vaccination programs can improve the vaccination rate for school-aged children, but getting tweens and teens to participate can be hard, based on a study of school districts in central Texas.

“Expansion of the school-based immunization trial from elementary to middle and high schools improved influenza immunization coverage in school-aged children to 40%,” Dr. Manjusha Gaglani said at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases. This compares with 30% coverage achieved with community-based vaccinations.

On average, influenza immunization coverage was 48%, 28%, and 22% for 26 elementary, 10 middle, and 8 high schools (public), respectively, in the 2007–2008 school year. Average coverage was 52% for parochial schools, 34% for home-schooled children, and 10% for public schools (K-12). The community-based influenza immunization field trial achieved influenza vaccine coverage of 15%–30% of school-aged children between 1998 and 2006. In 2007, a school-based trial was initiated in local elementary schools. The trial was expanded to middle and high schools during the 2008–2009 school year to increase influenza immunization coverage in school-aged children.

Middle and high school students had lower rates of vaccination coverage than elementary children, even though information packets were mailed directly to parents instead of having students take them home, as elementary school students did, said Dr. Gaglani, a pediatric infectious diseases specialist at the Scott and White ambulatory pediatric clinic in Temple, Tex.

The information packets included a letter to parents, a brochure on the program, an influenza vaccine permission form, an assent script for children, an optional nonparticipation form, information about live and inactivated influenza vaccines, and privacy authorization forms. Parents were asked to call with questions and could choose to be present for the immunization either at school or a pediatric clinic. Parents could state a preference for inactivated influenza vaccine and were asked to schedule second doses for eligible children at the Scott and White pediatric clinic.

Approximately 2–4 weeks before the scheduled influenza vaccination day, informed consent and assent were obtained from the parent and capable children 7 years of age or older. Influenza vaccine permission forms containing children's demographic and health information were completed, signed, and dated by the parent and child, and collected by teachers and/or school nurses. School staff organized student flow, and research staff triaged students for live or inactivated influenza vaccine based on the child's health information. Research, public health, and school nurses and investigators administered the vaccines during school hours. Vaccinated students were given a “Guide to Study Participants” and a 6-week health report postcard. Children also were offered “flu fighter” stickers.

The enhanced program involved health care entities and independent school districts. In the program's second year (2008–2009), children aged 4–18 years were enrolled from 45 intervention-area schools—7 public school districts and 5 parochial schools. Home-schooled children also were included.

In all, approximately 22,914 information packets were sent to students. Between Sept. 22 and Dec. 18, 2008, immunization day was conducted at 48 schools, 2 days each at two high schools, and at a church for home-schooled students. Students also were enrolled at the pediatric clinic during six weekend and nine evening clinics, and at one community event. Based on the preliminary results, live nasal spray influenza vaccine was administered to 77% of a total of 9,007 students enrolled in the program.

An additional 588 students and 60 students were immunized at the pediatric clinic and community event, respectively. In addition, 1,878 school staff were vaccinated (67% received the trivalent inactive vaccine). Of the 652 students who returned nonparticipation forms, 91 students reported receiving the influenza vaccine. Another 267 said they would receive the influenza vaccine from their physician.

Dr. Gaglani reported that she has received grants from MedImmune Inc., Sanofi Pasteur Inc., GlaxoSmithKline, and Novartis, and that she is a consultant/speaker for MedImmune and Sanofi Pasteur. In addition, Sanofi Pasteur supplied the vaccine used in the study.

BALTIMORE — School-based influenza vaccination programs can improve the vaccination rate for school-aged children, but getting tweens and teens to participate can be hard, based on a study of school districts in central Texas.

“Expansion of the school-based immunization trial from elementary to middle and high schools improved influenza immunization coverage in school-aged children to 40%,” Dr. Manjusha Gaglani said at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases. This compares with 30% coverage achieved with community-based vaccinations.

On average, influenza immunization coverage was 48%, 28%, and 22% for 26 elementary, 10 middle, and 8 high schools (public), respectively, in the 2007–2008 school year. Average coverage was 52% for parochial schools, 34% for home-schooled children, and 10% for public schools (K-12). The community-based influenza immunization field trial achieved influenza vaccine coverage of 15%–30% of school-aged children between 1998 and 2006. In 2007, a school-based trial was initiated in local elementary schools. The trial was expanded to middle and high schools during the 2008–2009 school year to increase influenza immunization coverage in school-aged children.

Middle and high school students had lower rates of vaccination coverage than elementary children, even though information packets were mailed directly to parents instead of having students take them home, as elementary school students did, said Dr. Gaglani, a pediatric infectious diseases specialist at the Scott and White ambulatory pediatric clinic in Temple, Tex.

The information packets included a letter to parents, a brochure on the program, an influenza vaccine permission form, an assent script for children, an optional nonparticipation form, information about live and inactivated influenza vaccines, and privacy authorization forms. Parents were asked to call with questions and could choose to be present for the immunization either at school or a pediatric clinic. Parents could state a preference for inactivated influenza vaccine and were asked to schedule second doses for eligible children at the Scott and White pediatric clinic.

Approximately 2–4 weeks before the scheduled influenza vaccination day, informed consent and assent were obtained from the parent and capable children 7 years of age or older. Influenza vaccine permission forms containing children's demographic and health information were completed, signed, and dated by the parent and child, and collected by teachers and/or school nurses. School staff organized student flow, and research staff triaged students for live or inactivated influenza vaccine based on the child's health information. Research, public health, and school nurses and investigators administered the vaccines during school hours. Vaccinated students were given a “Guide to Study Participants” and a 6-week health report postcard. Children also were offered “flu fighter” stickers.

The enhanced program involved health care entities and independent school districts. In the program's second year (2008–2009), children aged 4–18 years were enrolled from 45 intervention-area schools—7 public school districts and 5 parochial schools. Home-schooled children also were included.

In all, approximately 22,914 information packets were sent to students. Between Sept. 22 and Dec. 18, 2008, immunization day was conducted at 48 schools, 2 days each at two high schools, and at a church for home-schooled students. Students also were enrolled at the pediatric clinic during six weekend and nine evening clinics, and at one community event. Based on the preliminary results, live nasal spray influenza vaccine was administered to 77% of a total of 9,007 students enrolled in the program.

An additional 588 students and 60 students were immunized at the pediatric clinic and community event, respectively. In addition, 1,878 school staff were vaccinated (67% received the trivalent inactive vaccine). Of the 652 students who returned nonparticipation forms, 91 students reported receiving the influenza vaccine. Another 267 said they would receive the influenza vaccine from their physician.

Dr. Gaglani reported that she has received grants from MedImmune Inc., Sanofi Pasteur Inc., GlaxoSmithKline, and Novartis, and that she is a consultant/speaker for MedImmune and Sanofi Pasteur. In addition, Sanofi Pasteur supplied the vaccine used in the study.

BALTIMORE — Acetaminophen use may contribute to prolonged hospital stay and increased cost during asthma exacerbations in children, according to a retrospective study of 662 patients.

The average length of stay for children who received acetaminophen while in the hospital for an asthma exacerbation was 77 hours, compared with 56 hours for those who did not, Dr. Flory Nkoy and her colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies.

Similarly, the average cost of hospitalization for children who received acetaminophen was $4,580, compared with $3,201 for those who did not.

The researchers conducted a retrospective cohort study of children aged 2-17 years who were admitted to a tertiary care children's hospital with a primary diagnosis of asthma between January 2004 and December 2006, according to Dr. Nkoy of the division of pediatric inpatient medicine, University of Utah, Salt Lake City, and her colleagues.

A total of 662 children were admitted to the hospital for asthma during the study period. Of these, 21.5% received acetaminophen during their hospital stay and met the inclusion criteria. Patients with other chronic medical conditions or who received both acetaminophen and ibuprofen were excluded.

The researchers recorded acetaminophen prescription, number of doses, length of stay, and costs. Covariates included age, gender, case-mix severity index, body mass index, and presence of an infection. Multivariate linear and logistic regression analyses were used to determine whether the use of acetaminophen was associated with length of stay, costs, and resource utilization.

The relative resource use for patients who received acetaminophen, compared with those who didn't, was 36.3 vs. 25.5.

Dr. Nkoy did not report whether she had any relevant financial conflicts.

BALTIMORE — Acetaminophen use may contribute to prolonged hospital stay and increased cost during asthma exacerbations in children, according to a retrospective study of 662 patients.

The average length of stay for children who received acetaminophen while in the hospital for an asthma exacerbation was 77 hours, compared with 56 hours for those who did not, Dr. Flory Nkoy and her colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies.

Similarly, the average cost of hospitalization for children who received acetaminophen was $4,580, compared with $3,201 for those who did not.

The researchers conducted a retrospective cohort study of children aged 2-17 years who were admitted to a tertiary care children's hospital with a primary diagnosis of asthma between January 2004 and December 2006, according to Dr. Nkoy of the division of pediatric inpatient medicine, University of Utah, Salt Lake City, and her colleagues.

A total of 662 children were admitted to the hospital for asthma during the study period. Of these, 21.5% received acetaminophen during their hospital stay and met the inclusion criteria. Patients with other chronic medical conditions or who received both acetaminophen and ibuprofen were excluded.

The researchers recorded acetaminophen prescription, number of doses, length of stay, and costs. Covariates included age, gender, case-mix severity index, body mass index, and presence of an infection. Multivariate linear and logistic regression analyses were used to determine whether the use of acetaminophen was associated with length of stay, costs, and resource utilization.

The relative resource use for patients who received acetaminophen, compared with those who didn't, was 36.3 vs. 25.5.

Dr. Nkoy did not report whether she had any relevant financial conflicts.

BALTIMORE — Acetaminophen use may contribute to prolonged hospital stay and increased cost during asthma exacerbations in children, according to a retrospective study of 662 patients.

The average length of stay for children who received acetaminophen while in the hospital for an asthma exacerbation was 77 hours, compared with 56 hours for those who did not, Dr. Flory Nkoy and her colleagues reported in a poster at the annual meeting of the Pediatric Academic Societies.

Similarly, the average cost of hospitalization for children who received acetaminophen was $4,580, compared with $3,201 for those who did not.

The researchers conducted a retrospective cohort study of children aged 2-17 years who were admitted to a tertiary care children's hospital with a primary diagnosis of asthma between January 2004 and December 2006, according to Dr. Nkoy of the division of pediatric inpatient medicine, University of Utah, Salt Lake City, and her colleagues.

A total of 662 children were admitted to the hospital for asthma during the study period. Of these, 21.5% received acetaminophen during their hospital stay and met the inclusion criteria. Patients with other chronic medical conditions or who received both acetaminophen and ibuprofen were excluded.

The researchers recorded acetaminophen prescription, number of doses, length of stay, and costs. Covariates included age, gender, case-mix severity index, body mass index, and presence of an infection. Multivariate linear and logistic regression analyses were used to determine whether the use of acetaminophen was associated with length of stay, costs, and resource utilization.

The relative resource use for patients who received acetaminophen, compared with those who didn't, was 36.3 vs. 25.5.

Dr. Nkoy did not report whether she had any relevant financial conflicts.

BALTIMORE — Parasite infections may not be one of the more common conditions treated by dermatologists, but the creepiness factor makes them stand out, judging from the series of anecdotes and advice presented by Dr. Dirk Elston.

"If you're not squirming by the end of this lecture, I have not done my job," joked Dr. Elston, at the Atlantic Dermatological Conference.

Dr. Elston, director of the dermatology department at Geisinger Medical Center in Danville, Pa., provided helpful tips and more than a few gross-out moments during his presentation on onchocercoma, Sparganum proliferum, cutaneous larva migrans, myiasis, Amblyomma americanum, and lice and scabies.

Onchocercoma

An onchocercoma is a dermal or subdermal ball of writhing worms (Onchocerca), for which humans are the definitive host. Dirofilaria (heartworms) should be included in the differential diagnosis for onchocercoma, said Dr. Elston. However, humans are an accidental host for Dirofilaria.

"You develop a rip-roaring immune response to Dirofilaria in the form of an abscess, which you don't see with Onchocerca." It is possible to tell the two apart on histology. Dirofilaria is very muscular on histology, while Onchocerca has no muscle tone. In addition, Dirofilaria has a distinct ridge pattern on histology.

Sparganum proliferum

Dr. Elston described the case of a man, who was involved in a motorcycle accident years earlier. The local farmers had treated him with a meat poultice, which apparently contained a tapeworm (S. proliferum) that migrated into his body. He presented 40 years later with a multilocular cyst that contained the live tapeworm, when excised.

S. proliferum has all the features of a cestode: an intact secretory tegument, subtegumental cells, and smooth muscle cells. Many types of cestodes can live for many years and can reproduce asexually.

Cutaneous Larva Migrans

Cutaneous larva migrans (caused by worms) manifests as an erythematous, serpiginous, pruritic, cutaneous eruption caused by accidental percutaneous penetration.

"The trick is finding the worm, which can be anywhere within a centimeter [of the eruption]," said Dr. Elston. However, "nowadays, we tend to use ivermectin orally, off label." This systemic treatment does not require finding the worm.

Myiasis

Myiasis is infestation by the larvae (maggots) of dipterous (two-winged) flies and occurs most frequently in tropical climates. Dr. Elston related a story about an excised cyst. The patient had returned to the surgeon with wound infection and dehiscence, and "as he was injecting the wound … something shot out of it."

Standard treatment of myiasis is to cover the site with occlusive dressing to force the larvae out. "In this case, because there was secondary infection, we had to go in and clean it up," he said.

The patient's infestation involved the warble fly (Dermatobia hominis), the most common cause. "The warble is the furuncle; the bot is the organism in it," Dr. Elston noted.

Amblyomma americanum

A. americanum, the lone star tick, is "taking over the United States. Their range is now way up into the upper Midwest and through the Eastern seaboard. … They are becoming a very well-adapted tick," said Dr. Elston.

"They tend to attach in very, very large numbers," he noted. There are anecdotal stories of people crouching in the overgrown areas of Texas and having 2,000–3,000 ticks removed.

"Amblyomma likes the lower half of the body … and they carry Rocky Mountain spotted fever, tularemia, and human granulocytic ehrlichiosis," Dr. Elston said. These ticks are very small. "It's not until they start to engorge that people realize that they're ticks because they're so small that you don't even see them."

Patients with Amblyomma infection often present for generalized pruritus, but Amblyomma can be identified on histology, even when the tick has disintegrated. "There's this cement that retains the shape of the mouth; sometimes you'll see just that in the tissue," said Dr. Elston. This mouth-shaped cement is diagnostic. The infiltrate is characteristic with CD30-positive lymphocytes.

Lice and Scabies

Pubic lice can occur anywhere on the body, including the eyelashes. "So if you see lice or nits on the eyelashes, don't look north for the source of the infestation. Look south," said Dr. Elston.

With head lice, parents and teachers sometimes find hair casts and assume they have found nits. "There are kids who get sent home numerous times because of 'no-nit' policies at schools, who never had lice. They've got hair casts." This may lead to unnecessary overexposure to permethrin, which has been associated with childhood leukemia.

"Body lice are important internationally because they are vectors for disease," Dr. Elston noted. On histology, chitin scrolls (pigtails) are diagnostic of scabies.

Unfortunately, "there are sheets of Langerhans cells in the tissue induced by scabies," which have led to incorrect diagnosis and chemotherapy of children for Langerhans histiocytosis, said Dr. Elston at the meeting.

Dr. Elston said he had no relevant financial relationships.

'If you're not squirming by the end of this … Ihave not done my job.' DR. ELSTON

The exit site wound of a patient with a myiasis infestation is shown. The warble fly is the most common cause. SEPPäNEN M, ET AL. MYIASIS DURING ADVENTURE SPORTS RACE. EMERGING INFECT. DIS. 2004.

Lone star ticks are small in size, attach in large numbers, and carry disease. ©JAMES GATHANY/CDC

A papular, pruritic rash is commonly seen with scabies infection, as on the foot of this baby. Courtesy Dr. Dirk Elston

BALTIMORE — Parasite infections may not be one of the more common conditions treated by dermatologists, but the creepiness factor makes them stand out, judging from the series of anecdotes and advice presented by Dr. Dirk Elston.

"If you're not squirming by the end of this lecture, I have not done my job," joked Dr. Elston, at the Atlantic Dermatological Conference.

Dr. Elston, director of the dermatology department at Geisinger Medical Center in Danville, Pa., provided helpful tips and more than a few gross-out moments during his presentation on onchocercoma, Sparganum proliferum, cutaneous larva migrans, myiasis, Amblyomma americanum, and lice and scabies.

Onchocercoma

An onchocercoma is a dermal or subdermal ball of writhing worms (Onchocerca), for which humans are the definitive host. Dirofilaria (heartworms) should be included in the differential diagnosis for onchocercoma, said Dr. Elston. However, humans are an accidental host for Dirofilaria.

"You develop a rip-roaring immune response to Dirofilaria in the form of an abscess, which you don't see with Onchocerca." It is possible to tell the two apart on histology. Dirofilaria is very muscular on histology, while Onchocerca has no muscle tone. In addition, Dirofilaria has a distinct ridge pattern on histology.

Sparganum proliferum

Dr. Elston described the case of a man, who was involved in a motorcycle accident years earlier. The local farmers had treated him with a meat poultice, which apparently contained a tapeworm (S. proliferum) that migrated into his body. He presented 40 years later with a multilocular cyst that contained the live tapeworm, when excised.

S. proliferum has all the features of a cestode: an intact secretory tegument, subtegumental cells, and smooth muscle cells. Many types of cestodes can live for many years and can reproduce asexually.

Cutaneous Larva Migrans

Cutaneous larva migrans (caused by worms) manifests as an erythematous, serpiginous, pruritic, cutaneous eruption caused by accidental percutaneous penetration.

"The trick is finding the worm, which can be anywhere within a centimeter [of the eruption]," said Dr. Elston. However, "nowadays, we tend to use ivermectin orally, off label." This systemic treatment does not require finding the worm.

Myiasis

Myiasis is infestation by the larvae (maggots) of dipterous (two-winged) flies and occurs most frequently in tropical climates. Dr. Elston related a story about an excised cyst. The patient had returned to the surgeon with wound infection and dehiscence, and "as he was injecting the wound … something shot out of it."

Standard treatment of myiasis is to cover the site with occlusive dressing to force the larvae out. "In this case, because there was secondary infection, we had to go in and clean it up," he said.

The patient's infestation involved the warble fly (Dermatobia hominis), the most common cause. "The warble is the furuncle; the bot is the organism in it," Dr. Elston noted.

Amblyomma americanum

A. americanum, the lone star tick, is "taking over the United States. Their range is now way up into the upper Midwest and through the Eastern seaboard. … They are becoming a very well-adapted tick," said Dr. Elston.

"They tend to attach in very, very large numbers," he noted. There are anecdotal stories of people crouching in the overgrown areas of Texas and having 2,000–3,000 ticks removed.

"Amblyomma likes the lower half of the body … and they carry Rocky Mountain spotted fever, tularemia, and human granulocytic ehrlichiosis," Dr. Elston said. These ticks are very small. "It's not until they start to engorge that people realize that they're ticks because they're so small that you don't even see them."

Patients with Amblyomma infection often present for generalized pruritus, but Amblyomma can be identified on histology, even when the tick has disintegrated. "There's this cement that retains the shape of the mouth; sometimes you'll see just that in the tissue," said Dr. Elston. This mouth-shaped cement is diagnostic. The infiltrate is characteristic with CD30-positive lymphocytes.

Lice and Scabies

Pubic lice can occur anywhere on the body, including the eyelashes. "So if you see lice or nits on the eyelashes, don't look north for the source of the infestation. Look south," said Dr. Elston.

With head lice, parents and teachers sometimes find hair casts and assume they have found nits. "There are kids who get sent home numerous times because of 'no-nit' policies at schools, who never had lice. They've got hair casts." This may lead to unnecessary overexposure to permethrin, which has been associated with childhood leukemia.

"Body lice are important internationally because they are vectors for disease," Dr. Elston noted. On histology, chitin scrolls (pigtails) are diagnostic of scabies.

Unfortunately, "there are sheets of Langerhans cells in the tissue induced by scabies," which have led to incorrect diagnosis and chemotherapy of children for Langerhans histiocytosis, said Dr. Elston at the meeting.

Dr. Elston said he had no relevant financial relationships.

'If you're not squirming by the end of this … Ihave not done my job.' DR. ELSTON

The exit site wound of a patient with a myiasis infestation is shown. The warble fly is the most common cause. SEPPäNEN M, ET AL. MYIASIS DURING ADVENTURE SPORTS RACE. EMERGING INFECT. DIS. 2004.

Lone star ticks are small in size, attach in large numbers, and carry disease. ©JAMES GATHANY/CDC

A papular, pruritic rash is commonly seen with scabies infection, as on the foot of this baby. Courtesy Dr. Dirk Elston

BALTIMORE — Parasite infections may not be one of the more common conditions treated by dermatologists, but the creepiness factor makes them stand out, judging from the series of anecdotes and advice presented by Dr. Dirk Elston.

"If you're not squirming by the end of this lecture, I have not done my job," joked Dr. Elston, at the Atlantic Dermatological Conference.

Dr. Elston, director of the dermatology department at Geisinger Medical Center in Danville, Pa., provided helpful tips and more than a few gross-out moments during his presentation on onchocercoma, Sparganum proliferum, cutaneous larva migrans, myiasis, Amblyomma americanum, and lice and scabies.

Onchocercoma

An onchocercoma is a dermal or subdermal ball of writhing worms (Onchocerca), for which humans are the definitive host. Dirofilaria (heartworms) should be included in the differential diagnosis for onchocercoma, said Dr. Elston. However, humans are an accidental host for Dirofilaria.

"You develop a rip-roaring immune response to Dirofilaria in the form of an abscess, which you don't see with Onchocerca." It is possible to tell the two apart on histology. Dirofilaria is very muscular on histology, while Onchocerca has no muscle tone. In addition, Dirofilaria has a distinct ridge pattern on histology.

Sparganum proliferum

Dr. Elston described the case of a man, who was involved in a motorcycle accident years earlier. The local farmers had treated him with a meat poultice, which apparently contained a tapeworm (S. proliferum) that migrated into his body. He presented 40 years later with a multilocular cyst that contained the live tapeworm, when excised.

S. proliferum has all the features of a cestode: an intact secretory tegument, subtegumental cells, and smooth muscle cells. Many types of cestodes can live for many years and can reproduce asexually.

Cutaneous Larva Migrans

Cutaneous larva migrans (caused by worms) manifests as an erythematous, serpiginous, pruritic, cutaneous eruption caused by accidental percutaneous penetration.

"The trick is finding the worm, which can be anywhere within a centimeter [of the eruption]," said Dr. Elston. However, "nowadays, we tend to use ivermectin orally, off label." This systemic treatment does not require finding the worm.

Myiasis

Myiasis is infestation by the larvae (maggots) of dipterous (two-winged) flies and occurs most frequently in tropical climates. Dr. Elston related a story about an excised cyst. The patient had returned to the surgeon with wound infection and dehiscence, and "as he was injecting the wound … something shot out of it."

Standard treatment of myiasis is to cover the site with occlusive dressing to force the larvae out. "In this case, because there was secondary infection, we had to go in and clean it up," he said.

The patient's infestation involved the warble fly (Dermatobia hominis), the most common cause. "The warble is the furuncle; the bot is the organism in it," Dr. Elston noted.

Amblyomma americanum

A. americanum, the lone star tick, is "taking over the United States. Their range is now way up into the upper Midwest and through the Eastern seaboard. … They are becoming a very well-adapted tick," said Dr. Elston.

"They tend to attach in very, very large numbers," he noted. There are anecdotal stories of people crouching in the overgrown areas of Texas and having 2,000–3,000 ticks removed.

"Amblyomma likes the lower half of the body … and they carry Rocky Mountain spotted fever, tularemia, and human granulocytic ehrlichiosis," Dr. Elston said. These ticks are very small. "It's not until they start to engorge that people realize that they're ticks because they're so small that you don't even see them."

Patients with Amblyomma infection often present for generalized pruritus, but Amblyomma can be identified on histology, even when the tick has disintegrated. "There's this cement that retains the shape of the mouth; sometimes you'll see just that in the tissue," said Dr. Elston. This mouth-shaped cement is diagnostic. The infiltrate is characteristic with CD30-positive lymphocytes.

Lice and Scabies

Pubic lice can occur anywhere on the body, including the eyelashes. "So if you see lice or nits on the eyelashes, don't look north for the source of the infestation. Look south," said Dr. Elston.

With head lice, parents and teachers sometimes find hair casts and assume they have found nits. "There are kids who get sent home numerous times because of 'no-nit' policies at schools, who never had lice. They've got hair casts." This may lead to unnecessary overexposure to permethrin, which has been associated with childhood leukemia.

"Body lice are important internationally because they are vectors for disease," Dr. Elston noted. On histology, chitin scrolls (pigtails) are diagnostic of scabies.

Unfortunately, "there are sheets of Langerhans cells in the tissue induced by scabies," which have led to incorrect diagnosis and chemotherapy of children for Langerhans histiocytosis, said Dr. Elston at the meeting.

Dr. Elston said he had no relevant financial relationships.

'If you're not squirming by the end of this … Ihave not done my job.' DR. ELSTON

The exit site wound of a patient with a myiasis infestation is shown. The warble fly is the most common cause. SEPPäNEN M, ET AL. MYIASIS DURING ADVENTURE SPORTS RACE. EMERGING INFECT. DIS. 2004.

Lone star ticks are small in size, attach in large numbers, and carry disease. ©JAMES GATHANY/CDC

A papular, pruritic rash is commonly seen with scabies infection, as on the foot of this baby. Courtesy Dr. Dirk Elston

BALTIMORE — Despite the introduction of the varicella vaccine, central nervous system disease continues to be associated with varicella zoster virus and in rare cases can even result from reactivated vaccine strains, a study of 26 California cases shows.

Dr. Barbara Pahud and her colleagues identified 41 varicella zoster virus (VZV)-positive cases within the California Encephalitis Project (CEP), which runs standardized panels of diagnostic tests on specimens from cases of central nervous system (CNS) disease referred by physicians.

Dr. Pahud is a clinical fellow in pediatric infectious diseases at the University of California, San Francisco, and she presented the study findings in a poster at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases.

Four real-time polymerase chain reaction protocols were used to target four vaccine-associated single-base polymorphisms, allowing the identification of VZV-positive specimens and discrimination of vaccine (vOka) from wild- type VZV strains. Cerebral spinal fluid samples were sent to the CDC for genotyping. Additional clinical information was requested for the 26 cases that were successfully genotyped. The median age of this cohort was 46 years; slightly more than half (53%) were white.

"This report includes the fourth documented case of VZV vaccine strain associated with CNS disease, presenting 11 years post immunization [with] meningitis and herpes zoster rash," the researchers wrote.

This strain was found in a previously healthy 12-year-old girl, who presented with meningitis symptoms. Notably, clinical presentation for this case did not differ from that of wild-type varicella-associated CNS disease, "making the diagnosis of vaccine strain reactivation difficult based on clinical presentation alone."

VZV isolates can be divided into three genotypes: European, Japanese, and mosaic. In the United States, the predominant circulating genotype is the European one (82%).

The Oka vaccine strain belongs to the Japanese genotype. Sequencing data from the California cohort show that no one genotype predominates. In addition, the wild- type Japanese strains appear to be more common than has been previously reported.

Varicella-associated CNS reactivation occurs in both immunocompromised and immunocompetent individuals, who might or might not present with herpes zoster (HZ) rash. In this cohort "only 42% of cases presented with an HZ rash. Clinicians should maintain a high index of suspicion in diagnosing VZV in patients with CNS infection, since more often than not, it presents without the characteristic rash of primary varicella or HZ reactivation," the researchers noted.

Four out of the seven pediatric patients had no history of primary varicella disease. Varicella-associated CNS disease in these patients could be secondary to reactivation or caused by a first-time varicella rash, they wrote.

The live attenuated VZV vaccine was introduced in 1996. More than 50 million doses have been distributed in the United States since then. Current recommendations are two doses for children and other healthy people without evidence of immunity.

The study was funded through a subcontract with America's Health Insurance Plans under a contract from the Centers for Disease Control and Prevention.

BALTIMORE — Despite the introduction of the varicella vaccine, central nervous system disease continues to be associated with varicella zoster virus and in rare cases can even result from reactivated vaccine strains, a study of 26 California cases shows.

Dr. Barbara Pahud and her colleagues identified 41 varicella zoster virus (VZV)-positive cases within the California Encephalitis Project (CEP), which runs standardized panels of diagnostic tests on specimens from cases of central nervous system (CNS) disease referred by physicians.

Dr. Pahud is a clinical fellow in pediatric infectious diseases at the University of California, San Francisco, and she presented the study findings in a poster at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases.

Four real-time polymerase chain reaction protocols were used to target four vaccine-associated single-base polymorphisms, allowing the identification of VZV-positive specimens and discrimination of vaccine (vOka) from wild- type VZV strains. Cerebral spinal fluid samples were sent to the CDC for genotyping. Additional clinical information was requested for the 26 cases that were successfully genotyped. The median age of this cohort was 46 years; slightly more than half (53%) were white.

"This report includes the fourth documented case of VZV vaccine strain associated with CNS disease, presenting 11 years post immunization [with] meningitis and herpes zoster rash," the researchers wrote.

This strain was found in a previously healthy 12-year-old girl, who presented with meningitis symptoms. Notably, clinical presentation for this case did not differ from that of wild-type varicella-associated CNS disease, "making the diagnosis of vaccine strain reactivation difficult based on clinical presentation alone."

VZV isolates can be divided into three genotypes: European, Japanese, and mosaic. In the United States, the predominant circulating genotype is the European one (82%).

The Oka vaccine strain belongs to the Japanese genotype. Sequencing data from the California cohort show that no one genotype predominates. In addition, the wild- type Japanese strains appear to be more common than has been previously reported.

Varicella-associated CNS reactivation occurs in both immunocompromised and immunocompetent individuals, who might or might not present with herpes zoster (HZ) rash. In this cohort "only 42% of cases presented with an HZ rash. Clinicians should maintain a high index of suspicion in diagnosing VZV in patients with CNS infection, since more often than not, it presents without the characteristic rash of primary varicella or HZ reactivation," the researchers noted.

Four out of the seven pediatric patients had no history of primary varicella disease. Varicella-associated CNS disease in these patients could be secondary to reactivation or caused by a first-time varicella rash, they wrote.

The live attenuated VZV vaccine was introduced in 1996. More than 50 million doses have been distributed in the United States since then. Current recommendations are two doses for children and other healthy people without evidence of immunity.

The study was funded through a subcontract with America's Health Insurance Plans under a contract from the Centers for Disease Control and Prevention.

BALTIMORE — Despite the introduction of the varicella vaccine, central nervous system disease continues to be associated with varicella zoster virus and in rare cases can even result from reactivated vaccine strains, a study of 26 California cases shows.

Dr. Barbara Pahud and her colleagues identified 41 varicella zoster virus (VZV)-positive cases within the California Encephalitis Project (CEP), which runs standardized panels of diagnostic tests on specimens from cases of central nervous system (CNS) disease referred by physicians.

Dr. Pahud is a clinical fellow in pediatric infectious diseases at the University of California, San Francisco, and she presented the study findings in a poster at a conference on vaccine research sponsored by the National Foundation for Infectious Diseases.

Four real-time polymerase chain reaction protocols were used to target four vaccine-associated single-base polymorphisms, allowing the identification of VZV-positive specimens and discrimination of vaccine (vOka) from wild- type VZV strains. Cerebral spinal fluid samples were sent to the CDC for genotyping. Additional clinical information was requested for the 26 cases that were successfully genotyped. The median age of this cohort was 46 years; slightly more than half (53%) were white.

"This report includes the fourth documented case of VZV vaccine strain associated with CNS disease, presenting 11 years post immunization [with] meningitis and herpes zoster rash," the researchers wrote.

This strain was found in a previously healthy 12-year-old girl, who presented with meningitis symptoms. Notably, clinical presentation for this case did not differ from that of wild-type varicella-associated CNS disease, "making the diagnosis of vaccine strain reactivation difficult based on clinical presentation alone."

VZV isolates can be divided into three genotypes: European, Japanese, and mosaic. In the United States, the predominant circulating genotype is the European one (82%).

The Oka vaccine strain belongs to the Japanese genotype. Sequencing data from the California cohort show that no one genotype predominates. In addition, the wild- type Japanese strains appear to be more common than has been previously reported.

Varicella-associated CNS reactivation occurs in both immunocompromised and immunocompetent individuals, who might or might not present with herpes zoster (HZ) rash. In this cohort "only 42% of cases presented with an HZ rash. Clinicians should maintain a high index of suspicion in diagnosing VZV in patients with CNS infection, since more often than not, it presents without the characteristic rash of primary varicella or HZ reactivation," the researchers noted.

Four out of the seven pediatric patients had no history of primary varicella disease. Varicella-associated CNS disease in these patients could be secondary to reactivation or caused by a first-time varicella rash, they wrote.

The live attenuated VZV vaccine was introduced in 1996. More than 50 million doses have been distributed in the United States since then. Current recommendations are two doses for children and other healthy people without evidence of immunity.

The study was funded through a subcontract with America's Health Insurance Plans under a contract from the Centers for Disease Control and Prevention.

WASHINGTON — Pediatric patients with severe asthma are younger, use fewer oral steroids, and take lower doses of inhaled steroids today than they did 10 years ago, based on data from a single-center study of more than 200 patients.

“The use of highly effective medications, developed over the past decade, appears to have changed the clinical manifestations of severe childhood asthma,” Dr. Joseph Spahn said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Spahn and his coinvestigators performed a retrospective study of 65 children (aged 6-18 years) referred to a pediatric day program at National Jewish Health for severe asthma between 2004 and 2007. The results were compared with those for a published study of a cohort of 163 children with severe asthma at the facility from 1993 to 1997. Dr. Spahn is the director of the immunopharmacology laboratory at National Jewish Health in Denver.

“Over a 3-year period, we only accumulated 65 children with severe asthma. That doesn't mean that we're going out of business because we're not seeing patients any more. Our floors are filled with little kids with severe eczema and multiple food allergies; they're no longer filled with kids with oral steroid-dependent asthma,” he noted.

The present cohort was younger (a mean 11 years vs. 14 years). The recent cohort also had an earlier age of asthma onset (a mean 3 years vs. 10 years), and had lower percentiles for height (53 vs. 39), weight (71 vs. 68), and body mass index (77 vs. 74).

In addition, “we are seeing fewer children who require chronically administered oral steroid therapy,” he said. The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. The duration of oral steroid use also fell from 34 months to 18 months, and the average inhaled steroid dose dropped, from 1,691 mcg to 764 mcg.

There is “an obvious and very distinct difference in the types of inhaled steroids that we use today compared to more than a decade ago,” said Dr. Spahn. Children in the current cohort are on second-generation steroids or beclomethasone in an improved delivery device.

In the latest cohort, 77% of patients were on a leukotriene receptor antagonist, 66% were on a combination inhaled-steroid/long-acting beta-agonist. None of the historic cohort received those medications. In addition, the present cohort had higher measures of forced expiratory volume in 1 second (84% vs. 76% of predicted), required less albuterol (34 vs. 72 inhalations per week), and had fewer intubations in the past (13% vs. 21%). The present cohort also had fewer steroid-induced adverse effects.

Dr. Spahn reported that he has received honoraria from both GlaxoSmithKline and Merck & Co. He disclosed that he has also received research support from GSK, Merck, and AstraZeneca Pharmaceuticals LP.

The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. Elsevier Global Medical News

WASHINGTON — Pediatric patients with severe asthma are younger, use fewer oral steroids, and take lower doses of inhaled steroids today than they did 10 years ago, based on data from a single-center study of more than 200 patients.

“The use of highly effective medications, developed over the past decade, appears to have changed the clinical manifestations of severe childhood asthma,” Dr. Joseph Spahn said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Spahn and his coinvestigators performed a retrospective study of 65 children (aged 6-18 years) referred to a pediatric day program at National Jewish Health for severe asthma between 2004 and 2007. The results were compared with those for a published study of a cohort of 163 children with severe asthma at the facility from 1993 to 1997. Dr. Spahn is the director of the immunopharmacology laboratory at National Jewish Health in Denver.

“Over a 3-year period, we only accumulated 65 children with severe asthma. That doesn't mean that we're going out of business because we're not seeing patients any more. Our floors are filled with little kids with severe eczema and multiple food allergies; they're no longer filled with kids with oral steroid-dependent asthma,” he noted.

The present cohort was younger (a mean 11 years vs. 14 years). The recent cohort also had an earlier age of asthma onset (a mean 3 years vs. 10 years), and had lower percentiles for height (53 vs. 39), weight (71 vs. 68), and body mass index (77 vs. 74).

In addition, “we are seeing fewer children who require chronically administered oral steroid therapy,” he said. The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. The duration of oral steroid use also fell from 34 months to 18 months, and the average inhaled steroid dose dropped, from 1,691 mcg to 764 mcg.

There is “an obvious and very distinct difference in the types of inhaled steroids that we use today compared to more than a decade ago,” said Dr. Spahn. Children in the current cohort are on second-generation steroids or beclomethasone in an improved delivery device.

In the latest cohort, 77% of patients were on a leukotriene receptor antagonist, 66% were on a combination inhaled-steroid/long-acting beta-agonist. None of the historic cohort received those medications. In addition, the present cohort had higher measures of forced expiratory volume in 1 second (84% vs. 76% of predicted), required less albuterol (34 vs. 72 inhalations per week), and had fewer intubations in the past (13% vs. 21%). The present cohort also had fewer steroid-induced adverse effects.

Dr. Spahn reported that he has received honoraria from both GlaxoSmithKline and Merck & Co. He disclosed that he has also received research support from GSK, Merck, and AstraZeneca Pharmaceuticals LP.

The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. Elsevier Global Medical News

WASHINGTON — Pediatric patients with severe asthma are younger, use fewer oral steroids, and take lower doses of inhaled steroids today than they did 10 years ago, based on data from a single-center study of more than 200 patients.

“The use of highly effective medications, developed over the past decade, appears to have changed the clinical manifestations of severe childhood asthma,” Dr. Joseph Spahn said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Spahn and his coinvestigators performed a retrospective study of 65 children (aged 6-18 years) referred to a pediatric day program at National Jewish Health for severe asthma between 2004 and 2007. The results were compared with those for a published study of a cohort of 163 children with severe asthma at the facility from 1993 to 1997. Dr. Spahn is the director of the immunopharmacology laboratory at National Jewish Health in Denver.

“Over a 3-year period, we only accumulated 65 children with severe asthma. That doesn't mean that we're going out of business because we're not seeing patients any more. Our floors are filled with little kids with severe eczema and multiple food allergies; they're no longer filled with kids with oral steroid-dependent asthma,” he noted.

The present cohort was younger (a mean 11 years vs. 14 years). The recent cohort also had an earlier age of asthma onset (a mean 3 years vs. 10 years), and had lower percentiles for height (53 vs. 39), weight (71 vs. 68), and body mass index (77 vs. 74).

In addition, “we are seeing fewer children who require chronically administered oral steroid therapy,” he said. The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. The duration of oral steroid use also fell from 34 months to 18 months, and the average inhaled steroid dose dropped, from 1,691 mcg to 764 mcg.

There is “an obvious and very distinct difference in the types of inhaled steroids that we use today compared to more than a decade ago,” said Dr. Spahn. Children in the current cohort are on second-generation steroids or beclomethasone in an improved delivery device.

In the latest cohort, 77% of patients were on a leukotriene receptor antagonist, 66% were on a combination inhaled-steroid/long-acting beta-agonist. None of the historic cohort received those medications. In addition, the present cohort had higher measures of forced expiratory volume in 1 second (84% vs. 76% of predicted), required less albuterol (34 vs. 72 inhalations per week), and had fewer intubations in the past (13% vs. 21%). The present cohort also had fewer steroid-induced adverse effects.

Dr. Spahn reported that he has received honoraria from both GlaxoSmithKline and Merck & Co. He disclosed that he has also received research support from GSK, Merck, and AstraZeneca Pharmaceuticals LP.

The percentage requiring chronic oral steroid therapy dropped from 51% in the historic cohort to 28% in the most recent cohort. Elsevier Global Medical News

The use of imaging techniques other than x-ray is not nearly as widespread for psoriatic arthritis as it is for rheumatoid arthritis, and there are no guidelines on their use in this disease, according to Dr. Philip G. Conaghan, professor of musculoskeletal medicine at the University of Leeds in England. “For the vast majority of clinicians, x-rays are still the first line of investigation.”

In part, the imaging approach is dictated by the subtype of psoriatic arthritis (PsA). For example, in the spondylitic subtype with axial involvement, the work-up would be similar to that for a patient with inflammatory back pain: x-rays of the sacroiliac joints, followed by MRI if necessary.

For peripheral PsA, x-rays of the hand joints would be performed first to detect erosions and evidence of new bone formation. “In the clear-cut patient, who's got a dactylitic digit, often imaging won't be required. You'll make a clinical diagnosis in those patients, especially if there's a history of psoriasis or nail pitting or other features that lead you to think this is a psoriatic arthritis,” he said.

There are considerably fewer data on MRI and ultrasound in PsA than in rheumatoid arthritis (RA), but “before there's any bone damage, there's soft tissue inflammation,” said Dr. Conaghan, cochair of the OMERACT (Outcome Measures in Rheumatology) MRI Inflammatory Arthritis Task Force. Imaging modalities like MRI and ultrasound that pick up soft tissue abnormalities earlier than x-ray may be more useful.

“What we see with PsA—being typically seronegative—is that a lot of that inflammation is more than just intra-articular synovitis, as we see in RA. You see a lot of extra-articular inflammation. So you find more tenosynovitis, more subcutaneous edema, and sometimes enthesitis,” said Dr. Conaghan, who contributed to the OMERACT rheumatoid arthritis MRI reference image atlas. “Both ultrasound and MRI have a role to play in managing this disease, depending on their availability at your center.” Both techniques are useful for identifying tenosynovitis and synovitis. Ultrasound allows physicians to pick up subcutaneous edema at lower levels than would be possible on a physical examination.

For MRI, sequences that pick up inflammation—gadolinium-enhanced or STIR sequences—are the most useful, said Dr. Conaghan. “For peripheral joint PsA, you could use patient-friendly extremity MRI. [Magnet strength] anywhere from 0.2 T up to 3 T could be used.”

Ultrasound and MRI are both sensitive to inflammation, but “the link between inflammation and joint damage has not been as strongly made for PsA as for RA,” Dr. Conaghan noted. Several groups are looking at clarifying this link. “Once that has been achieved, there will be more rationale for stamping out inflammation.” Researchers will need to do large randomized trials to see if the suppression of inflammation can slow structural disease progression, as it does in RA.

There are no guidelines for using MRI or ultrasound to diagnose and follow patients with PsA at the moment; current clinical practice relies on clinical markers. However, OMERACT is developing a scoring system for peripheral PsA. The largest challenge that the group faces is that “we just don't have a lot of MR data sets [on PsA] available for us to look at,” said Dr. Conaghan. “We welcome hearing from groups with such MRI sets.”

Several groups are working on scoring systems for enthesitis using both ultrasound and MRI. Some of this work will be updated at the European League Against Rheumatism congress this summer. Work on evaluating MRI for the assessment of PsA is also ongoing, but these large imaging datasets are at least 1-2 years down the road. The OMERACT scoring system may be ready for validation in the next year.

Another problem with developing imaging guidelines for PsA is that disease involvement may be much more sporadic. “So you have fewer joints to evaluate per person, meaning that you might need larger datasets to show change.”

Ultrasound and MRI are likely to be used in the future in the drug development process to show effectiveness of investigational drugs over time.

MRI with gadolinium contrast reveals dactylitis in the toe of this patient. Courtesy Dr. Philip Helliwell and Dr. Clare Groves

The use of imaging techniques other than x-ray is not nearly as widespread for psoriatic arthritis as it is for rheumatoid arthritis, and there are no guidelines on their use in this disease, according to Dr. Philip G. Conaghan, professor of musculoskeletal medicine at the University of Leeds in England. “For the vast majority of clinicians, x-rays are still the first line of investigation.”

In part, the imaging approach is dictated by the subtype of psoriatic arthritis (PsA). For example, in the spondylitic subtype with axial involvement, the work-up would be similar to that for a patient with inflammatory back pain: x-rays of the sacroiliac joints, followed by MRI if necessary.

For peripheral PsA, x-rays of the hand joints would be performed first to detect erosions and evidence of new bone formation. “In the clear-cut patient, who's got a dactylitic digit, often imaging won't be required. You'll make a clinical diagnosis in those patients, especially if there's a history of psoriasis or nail pitting or other features that lead you to think this is a psoriatic arthritis,” he said.

There are considerably fewer data on MRI and ultrasound in PsA than in rheumatoid arthritis (RA), but “before there's any bone damage, there's soft tissue inflammation,” said Dr. Conaghan, cochair of the OMERACT (Outcome Measures in Rheumatology) MRI Inflammatory Arthritis Task Force. Imaging modalities like MRI and ultrasound that pick up soft tissue abnormalities earlier than x-ray may be more useful.

“What we see with PsA—being typically seronegative—is that a lot of that inflammation is more than just intra-articular synovitis, as we see in RA. You see a lot of extra-articular inflammation. So you find more tenosynovitis, more subcutaneous edema, and sometimes enthesitis,” said Dr. Conaghan, who contributed to the OMERACT rheumatoid arthritis MRI reference image atlas. “Both ultrasound and MRI have a role to play in managing this disease, depending on their availability at your center.” Both techniques are useful for identifying tenosynovitis and synovitis. Ultrasound allows physicians to pick up subcutaneous edema at lower levels than would be possible on a physical examination.

For MRI, sequences that pick up inflammation—gadolinium-enhanced or STIR sequences—are the most useful, said Dr. Conaghan. “For peripheral joint PsA, you could use patient-friendly extremity MRI. [Magnet strength] anywhere from 0.2 T up to 3 T could be used.”

Ultrasound and MRI are both sensitive to inflammation, but “the link between inflammation and joint damage has not been as strongly made for PsA as for RA,” Dr. Conaghan noted. Several groups are looking at clarifying this link. “Once that has been achieved, there will be more rationale for stamping out inflammation.” Researchers will need to do large randomized trials to see if the suppression of inflammation can slow structural disease progression, as it does in RA.

There are no guidelines for using MRI or ultrasound to diagnose and follow patients with PsA at the moment; current clinical practice relies on clinical markers. However, OMERACT is developing a scoring system for peripheral PsA. The largest challenge that the group faces is that “we just don't have a lot of MR data sets [on PsA] available for us to look at,” said Dr. Conaghan. “We welcome hearing from groups with such MRI sets.”

Several groups are working on scoring systems for enthesitis using both ultrasound and MRI. Some of this work will be updated at the European League Against Rheumatism congress this summer. Work on evaluating MRI for the assessment of PsA is also ongoing, but these large imaging datasets are at least 1-2 years down the road. The OMERACT scoring system may be ready for validation in the next year.

Another problem with developing imaging guidelines for PsA is that disease involvement may be much more sporadic. “So you have fewer joints to evaluate per person, meaning that you might need larger datasets to show change.”

Ultrasound and MRI are likely to be used in the future in the drug development process to show effectiveness of investigational drugs over time.

MRI with gadolinium contrast reveals dactylitis in the toe of this patient. Courtesy Dr. Philip Helliwell and Dr. Clare Groves

The use of imaging techniques other than x-ray is not nearly as widespread for psoriatic arthritis as it is for rheumatoid arthritis, and there are no guidelines on their use in this disease, according to Dr. Philip G. Conaghan, professor of musculoskeletal medicine at the University of Leeds in England. “For the vast majority of clinicians, x-rays are still the first line of investigation.”

In part, the imaging approach is dictated by the subtype of psoriatic arthritis (PsA). For example, in the spondylitic subtype with axial involvement, the work-up would be similar to that for a patient with inflammatory back pain: x-rays of the sacroiliac joints, followed by MRI if necessary.

For peripheral PsA, x-rays of the hand joints would be performed first to detect erosions and evidence of new bone formation. “In the clear-cut patient, who's got a dactylitic digit, often imaging won't be required. You'll make a clinical diagnosis in those patients, especially if there's a history of psoriasis or nail pitting or other features that lead you to think this is a psoriatic arthritis,” he said.

There are considerably fewer data on MRI and ultrasound in PsA than in rheumatoid arthritis (RA), but “before there's any bone damage, there's soft tissue inflammation,” said Dr. Conaghan, cochair of the OMERACT (Outcome Measures in Rheumatology) MRI Inflammatory Arthritis Task Force. Imaging modalities like MRI and ultrasound that pick up soft tissue abnormalities earlier than x-ray may be more useful.

“What we see with PsA—being typically seronegative—is that a lot of that inflammation is more than just intra-articular synovitis, as we see in RA. You see a lot of extra-articular inflammation. So you find more tenosynovitis, more subcutaneous edema, and sometimes enthesitis,” said Dr. Conaghan, who contributed to the OMERACT rheumatoid arthritis MRI reference image atlas. “Both ultrasound and MRI have a role to play in managing this disease, depending on their availability at your center.” Both techniques are useful for identifying tenosynovitis and synovitis. Ultrasound allows physicians to pick up subcutaneous edema at lower levels than would be possible on a physical examination.

For MRI, sequences that pick up inflammation—gadolinium-enhanced or STIR sequences—are the most useful, said Dr. Conaghan. “For peripheral joint PsA, you could use patient-friendly extremity MRI. [Magnet strength] anywhere from 0.2 T up to 3 T could be used.”

Ultrasound and MRI are both sensitive to inflammation, but “the link between inflammation and joint damage has not been as strongly made for PsA as for RA,” Dr. Conaghan noted. Several groups are looking at clarifying this link. “Once that has been achieved, there will be more rationale for stamping out inflammation.” Researchers will need to do large randomized trials to see if the suppression of inflammation can slow structural disease progression, as it does in RA.

There are no guidelines for using MRI or ultrasound to diagnose and follow patients with PsA at the moment; current clinical practice relies on clinical markers. However, OMERACT is developing a scoring system for peripheral PsA. The largest challenge that the group faces is that “we just don't have a lot of MR data sets [on PsA] available for us to look at,” said Dr. Conaghan. “We welcome hearing from groups with such MRI sets.”

Several groups are working on scoring systems for enthesitis using both ultrasound and MRI. Some of this work will be updated at the European League Against Rheumatism congress this summer. Work on evaluating MRI for the assessment of PsA is also ongoing, but these large imaging datasets are at least 1-2 years down the road. The OMERACT scoring system may be ready for validation in the next year.

Another problem with developing imaging guidelines for PsA is that disease involvement may be much more sporadic. “So you have fewer joints to evaluate per person, meaning that you might need larger datasets to show change.”

Ultrasound and MRI are likely to be used in the future in the drug development process to show effectiveness of investigational drugs over time.

MRI with gadolinium contrast reveals dactylitis in the toe of this patient. Courtesy Dr. Philip Helliwell and Dr. Clare Groves