Kate Johnson

TORONTO – Time and reimbursement are among the biggest concerns for physicians involved in helping patients with childhood-onset chronic diseases make the transition from pediatric to adult care, according to Dr. Megumi Okumura of the University of California, San Francisco.

“Many of these diseases are unfamiliar to adult providers because it is only recently that patients … have started surviving into adulthood,” she said at the annual meeting of the Pediatric Academic Societies. “In fact, many of these patients are largely cared for in the pediatric setting, even as adults.”

Surprisingly, however, it is not disease-specific knowledge and training that are the overriding concerns for pediatricians or internists as they help patients make the transition to adult care, she said. Instead, physicians cite lack of time, reimbursement, and psychiatric resources as their main obstacles.

“These patients require significant chronic-illness management and coordination with specialty care beyond what is typically done in the primary care setting,” she said. “A lot of the office infrastructure isn't there to help physicians coordinate this complex care. It doesn't really matter what the disease is, there just is not time in a primary care practice to [address] their needs,” she said in an interview.

Dr. Okumura presented her national survey of 492 internists and 730 pediatricians, in which she asked about disease-specific resources as well as barriers to overall care delivery for young adults with sickle cell disease, cystic fibrosis, and complex congenital heart disease.

She found that both pediatricians and internists reported reasonable access to general resources such as physical and occupational therapy, as well as disease-specific resources such as hematology, pulmonology, and cystic fibrosis or sickle cell disease centers.

Lack of psychiatric support was identified by pediatricians as the main obstacle (53%), followed by lack of time (42%), and lack of reimbursement (41%). For internists, reimbursement concerns were at the top of the list (35%), followed by time (33%), and lack of psychiatric support (28%).

When asked about factors associated with their ability to provide high-quality care for patients, both pediatricians and internists cited office structure, Dr. Okumura said.

“Internal practice-based barriers are more significant to clinicians than lack of external disease-specific resources or training,” she said, noting that lack of training was called a concern by 24% of internists and 12% of pediatricians.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Time and reimbursement are among the biggest concerns for physicians involved in helping patients with childhood-onset chronic diseases make the transition from pediatric to adult care, according to Dr. Megumi Okumura of the University of California, San Francisco.

“Many of these diseases are unfamiliar to adult providers because it is only recently that patients … have started surviving into adulthood,” she said at the annual meeting of the Pediatric Academic Societies. “In fact, many of these patients are largely cared for in the pediatric setting, even as adults.”

Surprisingly, however, it is not disease-specific knowledge and training that are the overriding concerns for pediatricians or internists as they help patients make the transition to adult care, she said. Instead, physicians cite lack of time, reimbursement, and psychiatric resources as their main obstacles.

“These patients require significant chronic-illness management and coordination with specialty care beyond what is typically done in the primary care setting,” she said. “A lot of the office infrastructure isn't there to help physicians coordinate this complex care. It doesn't really matter what the disease is, there just is not time in a primary care practice to [address] their needs,” she said in an interview.

Dr. Okumura presented her national survey of 492 internists and 730 pediatricians, in which she asked about disease-specific resources as well as barriers to overall care delivery for young adults with sickle cell disease, cystic fibrosis, and complex congenital heart disease.

She found that both pediatricians and internists reported reasonable access to general resources such as physical and occupational therapy, as well as disease-specific resources such as hematology, pulmonology, and cystic fibrosis or sickle cell disease centers.

Lack of psychiatric support was identified by pediatricians as the main obstacle (53%), followed by lack of time (42%), and lack of reimbursement (41%). For internists, reimbursement concerns were at the top of the list (35%), followed by time (33%), and lack of psychiatric support (28%).

When asked about factors associated with their ability to provide high-quality care for patients, both pediatricians and internists cited office structure, Dr. Okumura said.

“Internal practice-based barriers are more significant to clinicians than lack of external disease-specific resources or training,” she said, noting that lack of training was called a concern by 24% of internists and 12% of pediatricians.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Time and reimbursement are among the biggest concerns for physicians involved in helping patients with childhood-onset chronic diseases make the transition from pediatric to adult care, according to Dr. Megumi Okumura of the University of California, San Francisco.

“Many of these diseases are unfamiliar to adult providers because it is only recently that patients … have started surviving into adulthood,” she said at the annual meeting of the Pediatric Academic Societies. “In fact, many of these patients are largely cared for in the pediatric setting, even as adults.”

Surprisingly, however, it is not disease-specific knowledge and training that are the overriding concerns for pediatricians or internists as they help patients make the transition to adult care, she said. Instead, physicians cite lack of time, reimbursement, and psychiatric resources as their main obstacles.

“These patients require significant chronic-illness management and coordination with specialty care beyond what is typically done in the primary care setting,” she said. “A lot of the office infrastructure isn't there to help physicians coordinate this complex care. It doesn't really matter what the disease is, there just is not time in a primary care practice to [address] their needs,” she said in an interview.

Dr. Okumura presented her national survey of 492 internists and 730 pediatricians, in which she asked about disease-specific resources as well as barriers to overall care delivery for young adults with sickle cell disease, cystic fibrosis, and complex congenital heart disease.

She found that both pediatricians and internists reported reasonable access to general resources such as physical and occupational therapy, as well as disease-specific resources such as hematology, pulmonology, and cystic fibrosis or sickle cell disease centers.

Lack of psychiatric support was identified by pediatricians as the main obstacle (53%), followed by lack of time (42%), and lack of reimbursement (41%). For internists, reimbursement concerns were at the top of the list (35%), followed by time (33%), and lack of psychiatric support (28%).

When asked about factors associated with their ability to provide high-quality care for patients, both pediatricians and internists cited office structure, Dr. Okumura said.

“Internal practice-based barriers are more significant to clinicians than lack of external disease-specific resources or training,” she said, noting that lack of training was called a concern by 24% of internists and 12% of pediatricians.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% female, mean age of 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%).

▸ Urinary frequency (45%).

▸ Abdominal pain (45%).

▸ Hematuria (29%).

▸ Back pain (29%).

▸ Urgency (27%).

▸ Genital discharge (17%).

▸ Fever (17%).

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago. “There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in males “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STIs). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia, she said. Among the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55% of patients in the study represent “a missed opportunity for diagnosis and treatment of STI,” she concluded. “The first, most important reason is that we're not thinking about it,” she said. “And then there's also a whole number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult–[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents–with devastating consequences, she said. “Fifteen- to 25-year-olds have the highest rates of these diseases in the United States.” And adolescents seeking help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone. “In my practice … I always ask the mom to step out, because sometimes that's their only way into the medical system. And as soon as you shut the door, they start talking about birth control or STIs.”

TORONTO – Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% female, mean age of 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%).

▸ Urinary frequency (45%).

▸ Abdominal pain (45%).

▸ Hematuria (29%).

▸ Back pain (29%).

▸ Urgency (27%).

▸ Genital discharge (17%).

▸ Fever (17%).

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago. “There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in males “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STIs). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia, she said. Among the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55% of patients in the study represent “a missed opportunity for diagnosis and treatment of STI,” she concluded. “The first, most important reason is that we're not thinking about it,” she said. “And then there's also a whole number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult–[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents–with devastating consequences, she said. “Fifteen- to 25-year-olds have the highest rates of these diseases in the United States.” And adolescents seeking help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone. “In my practice … I always ask the mom to step out, because sometimes that's their only way into the medical system. And as soon as you shut the door, they start talking about birth control or STIs.”

TORONTO – Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% female, mean age of 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%).

▸ Urinary frequency (45%).

▸ Abdominal pain (45%).

▸ Hematuria (29%).

▸ Back pain (29%).

▸ Urgency (27%).

▸ Genital discharge (17%).

▸ Fever (17%).

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago. “There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in males “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STIs). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia, she said. Among the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55% of patients in the study represent “a missed opportunity for diagnosis and treatment of STI,” she concluded. “The first, most important reason is that we're not thinking about it,” she said. “And then there's also a whole number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult–[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents–with devastating consequences, she said. “Fifteen- to 25-year-olds have the highest rates of these diseases in the United States.” And adolescents seeking help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone. “In my practice … I always ask the mom to step out, because sometimes that's their only way into the medical system. And as soon as you shut the door, they start talking about birth control or STIs.”

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

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation.

“One certainly cannot ignore this report; it's a well-done study. We may discuss the finer details of interpreting them but I think the data seem to be believable,” he said in an interview.

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

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview.

The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Impact of Nonadherence

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

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

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

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

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old. “This child was not on a gluten-free diet, her parents did not consider it important, and she had to be admitted for hallucinations. It was a serious psychiatric problem, but putting her back on the diet resulted in a complete resolution within weeks,” he said.

The Impact of Adherence

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

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

The psychological research on adults regarding this question leaves little open to debate. The symbolism of “breaking bread” together–sharing in a common meal–crosses all cultural and religious boundaries, and studies have shown that adults with celiac disease struggle daily with their exclusion from, or isolation in, such rituals.

“There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. “A child doesn't necessarily have the developmental capacities to cope the way an adult might.”

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

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years.

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

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

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, noted the British authors. “Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, allergy, scoliosis, epilepsy, arthritis, kidney disease, and ocular conditions. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

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

While such options are becoming more widely offered, Dr. Edwards George said that children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “We hear a lot of stories about adolescents and young adults going away to college and then not being in that protective bubble anymore and having a really difficult time.”

Her research in the field of adult celiac disease is uncovering personality traits and coping mechanisms associated with better adjustment to and adherence to the diet–information she believes can be used to provide targeted guidance to children. “There are lots of strategies that can come from the psychological world that really can help,” she said. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious. It's not changing their personality but it's helping them change the environment around them to make them more likely to adhere.”

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

“Patients … learn to deal with hunger and do not notice hunger signs as often as someone else would,” because they are often faced with situations where there are no gluten-free options. Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern, especially in adolescent girls who are already more vulnerable to eating disorders. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

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

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

'I am personally convinced that eating gluten if you have celiac disease … induces serious changes in brain chemistry.' DR. GUANDALINI

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

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation.

“One certainly cannot ignore this report; it's a well-done study. We may discuss the finer details of interpreting them but I think the data seem to be believable,” he said in an interview.

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

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview.

The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Impact of Nonadherence

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

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

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

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

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old. “This child was not on a gluten-free diet, her parents did not consider it important, and she had to be admitted for hallucinations. It was a serious psychiatric problem, but putting her back on the diet resulted in a complete resolution within weeks,” he said.

The Impact of Adherence

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

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

The psychological research on adults regarding this question leaves little open to debate. The symbolism of “breaking bread” together–sharing in a common meal–crosses all cultural and religious boundaries, and studies have shown that adults with celiac disease struggle daily with their exclusion from, or isolation in, such rituals.

“There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. “A child doesn't necessarily have the developmental capacities to cope the way an adult might.”

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

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years.

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

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

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, noted the British authors. “Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, allergy, scoliosis, epilepsy, arthritis, kidney disease, and ocular conditions. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

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

While such options are becoming more widely offered, Dr. Edwards George said that children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “We hear a lot of stories about adolescents and young adults going away to college and then not being in that protective bubble anymore and having a really difficult time.”

Her research in the field of adult celiac disease is uncovering personality traits and coping mechanisms associated with better adjustment to and adherence to the diet–information she believes can be used to provide targeted guidance to children. “There are lots of strategies that can come from the psychological world that really can help,” she said. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious. It's not changing their personality but it's helping them change the environment around them to make them more likely to adhere.”

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

“Patients … learn to deal with hunger and do not notice hunger signs as often as someone else would,” because they are often faced with situations where there are no gluten-free options. Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern, especially in adolescent girls who are already more vulnerable to eating disorders. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

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

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

'I am personally convinced that eating gluten if you have celiac disease … induces serious changes in brain chemistry.' DR. GUANDALINI

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

The findings are “really surprising and unexpected,” according to Dr. Stefano Guandalini, chief of pediatric gastroenterology and director of the Celiac Disease Program at the University of Chicago. As one of the reviewers of the British study, he said he is confident that the increased mortality is more than a chance finding, but the reasons for it are open to interpretation.

“One certainly cannot ignore this report; it's a well-done study. We may discuss the finer details of interpreting them but I think the data seem to be believable,” he said in an interview.

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

“One explanation for this could be the psychological status of the children and possible changes in their risk-taking behaviors,” said Dr. Solaymani-Dodoran in an interview.

The median age at diagnosis was 1.5 years in study subjects diagnosed in childhood (compared with 46 years in those diagnosed as adults), with the threefold increased mortality risk remaining through adolescence and beyond, to more than 25 years after diagnosis.

The Impact of Nonadherence

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

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

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

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

“I am personally convinced that eating gluten if you have celiac disease really induces serious changes in brain chemistry that would make you inclined to aggressive, depressive behavior and therefore expose you to this risk,” said Dr. Guandalini, who has seen such psychiatric effects in a celiac patient as young as 5 years old. “This child was not on a gluten-free diet, her parents did not consider it important, and she had to be admitted for hallucinations. It was a serious psychiatric problem, but putting her back on the diet resulted in a complete resolution within weeks,” he said.

The Impact of Adherence

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

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

The psychological research on adults regarding this question leaves little open to debate. The symbolism of “breaking bread” together–sharing in a common meal–crosses all cultural and religious boundaries, and studies have shown that adults with celiac disease struggle daily with their exclusion from, or isolation in, such rituals.

“There's a lot of anger and frustration about the rigidity of the diet, as well as the fact that it is chronic,” said Sharon Jedel, Psy.D., a clinical psychologist at Rush University's adult celiac disease program in Chicago. “A child doesn't necessarily have the developmental capacities to cope the way an adult might.”

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

However, both Dr. Edwards George and Dr. Jedel treat psychological issues in adult patients only, and there are very few studies examining the social burden of following a gluten-free diet in the vulnerable adolescent years.

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

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

In Search of Normalcy

Even in the absence of anger or depression about their condition, adolescents with chronic diseases are more likely to be “risk takers,” and this is another possible explanation for the increased deaths by accident and violence, noted the British authors. “Adolescents in general don't have to prove they are 'normal', but adolescents with chronic conditions do,” explained Dr. Joan-Carles Suris, head of the research group on adolescent health at the Institute of Social and Preventive Medicine of the University of Lausanne (Switzerland).

In his analysis of almost 7,000 adolescents, 665 (9.5%) had a variety of chronic conditions including diabetes, asthma, allergy, scoliosis, epilepsy, arthritis, kidney disease, and ocular conditions. Dr. Suris found higher rates of risky sexual activity, history of pregnancy, history of sexually transmitted disease, smoking, drinking, and illegal drug use among those with the chronic conditions, compared with their healthy peers (Eur. J. Public Health 2005;15:484-8).

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

While such options are becoming more widely offered, Dr. Edwards George said that children with celiac disease also need the tools to cope in a gluten-filled world–lessons they might be taught with the help of more psychological research. “We hear a lot of stories about adolescents and young adults going away to college and then not being in that protective bubble anymore and having a really difficult time.”

Her research in the field of adult celiac disease is uncovering personality traits and coping mechanisms associated with better adjustment to and adherence to the diet–information she believes can be used to provide targeted guidance to children. “There are lots of strategies that can come from the psychological world that really can help,” she said. “They need skills to advocate for themselves, and we can build in supports to help them be more organized and more conscientious. It's not changing their personality but it's helping them change the environment around them to make them more likely to adhere.”

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

“Patients … learn to deal with hunger and do not notice hunger signs as often as someone else would,” because they are often faced with situations where there are no gluten-free options. Such disturbed eating patterns and hypervigilance, coupled with a common increase in weight after a malnourished patient is diagnosed and treated, can be a cause for concern, especially in adolescent girls who are already more vulnerable to eating disorders. In one of her studies “we did find some people who actually ate gluten in order to lose weight,” just as diabetic patients have been known to withhold insulin for the same reason, she said (Eur. J. Gastroenterol. Hepatol. 2007;19:251-5).

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

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

'I am personally convinced that eating gluten if you have celiac disease … induces serious changes in brain chemistry.' DR. GUANDALINI

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

BANFF, ALTA. — Combined spinal epidural produces a transient decrease in uterine but not umbilical artery blood flow that does not impact the fetal circulation, fetal heart rate pattern, or immediate neonatal outcome, according to the results of a small study.

“In normal pregnancies, we were able to a find a statistically but not clinically significant decrease in the uterine blood flow after CSE [combined spinal epidural],” Dr. Cristian Arzola said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The prospective study included 30 healthy patients in active labor with singleton, uncomplicated pregnancies at term. Pain, maternal blood pressure, fetal and maternal heart rate, blood-flow velocity waveforms, and pulsatility indices (PI) of the uterine and fetal umbilical arteries were measured before and at 5, 10, 15, and 30 minutes following administration of CSE (bupivacaine and fentanyl).

Dr. Arzola observed a drop in maternal systolic arterial blood pressure of 20% from baseline that was significant only at 10 and 15 minutes after CSE. Maternal heart rate dropped significantly at all time points, but remained within normal range. Pulsatility indices for the uterine artery were increased significantly at 10 minutes, indicating reduced blood flow; however, the PI for the umbilical artery remained stable, reported Dr. Arzola of the University of Chile, Santiago.

As expected, pain scores dropped dramatically, and with them adrenaline levels, which decreased more than 50% from baseline. Fetal heart rate did not change significantly, and tracings did not show altered patterns. Apgar scores and cord blood gases were all within normal range, and there were no signs of fetal distress, he said.

BANFF, ALTA. — Combined spinal epidural produces a transient decrease in uterine but not umbilical artery blood flow that does not impact the fetal circulation, fetal heart rate pattern, or immediate neonatal outcome, according to the results of a small study.

“In normal pregnancies, we were able to a find a statistically but not clinically significant decrease in the uterine blood flow after CSE [combined spinal epidural],” Dr. Cristian Arzola said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The prospective study included 30 healthy patients in active labor with singleton, uncomplicated pregnancies at term. Pain, maternal blood pressure, fetal and maternal heart rate, blood-flow velocity waveforms, and pulsatility indices (PI) of the uterine and fetal umbilical arteries were measured before and at 5, 10, 15, and 30 minutes following administration of CSE (bupivacaine and fentanyl).

Dr. Arzola observed a drop in maternal systolic arterial blood pressure of 20% from baseline that was significant only at 10 and 15 minutes after CSE. Maternal heart rate dropped significantly at all time points, but remained within normal range. Pulsatility indices for the uterine artery were increased significantly at 10 minutes, indicating reduced blood flow; however, the PI for the umbilical artery remained stable, reported Dr. Arzola of the University of Chile, Santiago.

As expected, pain scores dropped dramatically, and with them adrenaline levels, which decreased more than 50% from baseline. Fetal heart rate did not change significantly, and tracings did not show altered patterns. Apgar scores and cord blood gases were all within normal range, and there were no signs of fetal distress, he said.

BANFF, ALTA. — Combined spinal epidural produces a transient decrease in uterine but not umbilical artery blood flow that does not impact the fetal circulation, fetal heart rate pattern, or immediate neonatal outcome, according to the results of a small study.

“In normal pregnancies, we were able to a find a statistically but not clinically significant decrease in the uterine blood flow after CSE [combined spinal epidural],” Dr. Cristian Arzola said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The prospective study included 30 healthy patients in active labor with singleton, uncomplicated pregnancies at term. Pain, maternal blood pressure, fetal and maternal heart rate, blood-flow velocity waveforms, and pulsatility indices (PI) of the uterine and fetal umbilical arteries were measured before and at 5, 10, 15, and 30 minutes following administration of CSE (bupivacaine and fentanyl).

Dr. Arzola observed a drop in maternal systolic arterial blood pressure of 20% from baseline that was significant only at 10 and 15 minutes after CSE. Maternal heart rate dropped significantly at all time points, but remained within normal range. Pulsatility indices for the uterine artery were increased significantly at 10 minutes, indicating reduced blood flow; however, the PI for the umbilical artery remained stable, reported Dr. Arzola of the University of Chile, Santiago.

As expected, pain scores dropped dramatically, and with them adrenaline levels, which decreased more than 50% from baseline. Fetal heart rate did not change significantly, and tracings did not show altered patterns. Apgar scores and cord blood gases were all within normal range, and there were no signs of fetal distress, he said.

BANFF, ALTA. — An attempted external cephalic version and subsequent delivery costs more than a planned cesarean section for a term breech pregnancy, but it is still cost effective, based on national success rates for the maneuver, Jonathan Tan said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“ECV [external cephalic version] is cost effective when compared to scheduled cesarean for breech delivery if the probability of ECV success is above 46%,” said Mr. Tan, a medical student at State University of New York at Stony Brook.

“The 58% national average for ECV success in the United States puts us right in the range of cost-effectiveness, but it is still important to note that ECV costs more than a planned cesarean delivery,” Mr. Tan said.

A scheduled cesarean delivery costs around $7,200 while an ECV costs about $1,200 with an additional cost of $5,000 for a vaginal delivery, he said. However, not all ECV attempts are successful, and not all successes result in a vaginal delivery; “there are other indications for cesarean section,” he said.

In his analysis using a computer-based decision model, Mr. Tan used rates from the literature for successful ECV, spontaneous reversion, and probability of unanticipated emergency cesarean to calculate an incremental cost-effectiveness ratio of $31,600 per quality-adjusted life year gained for conducting a trial of ECV.

Although the American College of Obstetricians and Gynecologists currently recommends that all women near term with breech presentations should be offered a trial of ECV (ACOG Practice Bulletin Number 13, 2000), “in many hospitals in the United States, cesarean section is the exclusive method of management,” he said.

BANFF, ALTA. — An attempted external cephalic version and subsequent delivery costs more than a planned cesarean section for a term breech pregnancy, but it is still cost effective, based on national success rates for the maneuver, Jonathan Tan said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“ECV [external cephalic version] is cost effective when compared to scheduled cesarean for breech delivery if the probability of ECV success is above 46%,” said Mr. Tan, a medical student at State University of New York at Stony Brook.

“The 58% national average for ECV success in the United States puts us right in the range of cost-effectiveness, but it is still important to note that ECV costs more than a planned cesarean delivery,” Mr. Tan said.

A scheduled cesarean delivery costs around $7,200 while an ECV costs about $1,200 with an additional cost of $5,000 for a vaginal delivery, he said. However, not all ECV attempts are successful, and not all successes result in a vaginal delivery; “there are other indications for cesarean section,” he said.

In his analysis using a computer-based decision model, Mr. Tan used rates from the literature for successful ECV, spontaneous reversion, and probability of unanticipated emergency cesarean to calculate an incremental cost-effectiveness ratio of $31,600 per quality-adjusted life year gained for conducting a trial of ECV.

Although the American College of Obstetricians and Gynecologists currently recommends that all women near term with breech presentations should be offered a trial of ECV (ACOG Practice Bulletin Number 13, 2000), “in many hospitals in the United States, cesarean section is the exclusive method of management,” he said.

BANFF, ALTA. — An attempted external cephalic version and subsequent delivery costs more than a planned cesarean section for a term breech pregnancy, but it is still cost effective, based on national success rates for the maneuver, Jonathan Tan said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“ECV [external cephalic version] is cost effective when compared to scheduled cesarean for breech delivery if the probability of ECV success is above 46%,” said Mr. Tan, a medical student at State University of New York at Stony Brook.

“The 58% national average for ECV success in the United States puts us right in the range of cost-effectiveness, but it is still important to note that ECV costs more than a planned cesarean delivery,” Mr. Tan said.

A scheduled cesarean delivery costs around $7,200 while an ECV costs about $1,200 with an additional cost of $5,000 for a vaginal delivery, he said. However, not all ECV attempts are successful, and not all successes result in a vaginal delivery; “there are other indications for cesarean section,” he said.

In his analysis using a computer-based decision model, Mr. Tan used rates from the literature for successful ECV, spontaneous reversion, and probability of unanticipated emergency cesarean to calculate an incremental cost-effectiveness ratio of $31,600 per quality-adjusted life year gained for conducting a trial of ECV.

Although the American College of Obstetricians and Gynecologists currently recommends that all women near term with breech presentations should be offered a trial of ECV (ACOG Practice Bulletin Number 13, 2000), “in many hospitals in the United States, cesarean section is the exclusive method of management,” he said.

BANFF, ALTA. — Compared with extraabdominal uterine repair after cesarean section, the intraabdominal technique is associated with significantly less nausea and should be considered as the primary method for uterine repair, according to Dr. Jeanette Lager of the University of North Carolina at Chapel Hill.

“Uterine exteriorization is advantageous when exposure is difficult and many surgeons believe it is easier and more efficient,” said Dr. Lager, who presented her findings at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. Opposition to uterine exteriorization centers on concerns about hemodynamic instability, possible trauma to the uterine structures, and the potential for increased nausea, she said.

In her double-blinded, randomized trial, Dr. Lager found no difference between the two techniques in hemodynamic stability and estimated blood loss, although the intraabdominal technique was associated with a slightly longer operative time. “However, the difference was 7 minutes from skin [incision] to skin [closure] and 1 minute for uterine closure, so one could argue whether this is actually clinically significant,” she commented.

In terms of nausea, measured on a visual analog scale (VAS) ranging from 0 to 10, with 0 representing no nausea, mean nausea scores were considerably less in the 35 patients randomized to intraabdominal repair (2.3), compared with the 36 who received external repairs (4.6), she said. In addition, the rate of moderate to severe nausea was significantly lower in the intraabdominal group (35% vs. 67%). The intraabdominal group also used fewer antiemetics (18% vs. 23%) although this was not statistically significant, and VAS pain scores also showed a nonsignificant trend favoring the intraabdominal group, Dr. Lager said.

“Nausea is one of the most common concerns during cesarean delivery, second only to pain, and can interfere with uterine repair” if the patient is retching, she said, noting that according to an informal review at her hospital, 40% of women are pretreated or require treatment for nausea intraoperatively.

BANFF, ALTA. — Compared with extraabdominal uterine repair after cesarean section, the intraabdominal technique is associated with significantly less nausea and should be considered as the primary method for uterine repair, according to Dr. Jeanette Lager of the University of North Carolina at Chapel Hill.

“Uterine exteriorization is advantageous when exposure is difficult and many surgeons believe it is easier and more efficient,” said Dr. Lager, who presented her findings at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. Opposition to uterine exteriorization centers on concerns about hemodynamic instability, possible trauma to the uterine structures, and the potential for increased nausea, she said.

In her double-blinded, randomized trial, Dr. Lager found no difference between the two techniques in hemodynamic stability and estimated blood loss, although the intraabdominal technique was associated with a slightly longer operative time. “However, the difference was 7 minutes from skin [incision] to skin [closure] and 1 minute for uterine closure, so one could argue whether this is actually clinically significant,” she commented.

In terms of nausea, measured on a visual analog scale (VAS) ranging from 0 to 10, with 0 representing no nausea, mean nausea scores were considerably less in the 35 patients randomized to intraabdominal repair (2.3), compared with the 36 who received external repairs (4.6), she said. In addition, the rate of moderate to severe nausea was significantly lower in the intraabdominal group (35% vs. 67%). The intraabdominal group also used fewer antiemetics (18% vs. 23%) although this was not statistically significant, and VAS pain scores also showed a nonsignificant trend favoring the intraabdominal group, Dr. Lager said.

“Nausea is one of the most common concerns during cesarean delivery, second only to pain, and can interfere with uterine repair” if the patient is retching, she said, noting that according to an informal review at her hospital, 40% of women are pretreated or require treatment for nausea intraoperatively.

BANFF, ALTA. — Compared with extraabdominal uterine repair after cesarean section, the intraabdominal technique is associated with significantly less nausea and should be considered as the primary method for uterine repair, according to Dr. Jeanette Lager of the University of North Carolina at Chapel Hill.

“Uterine exteriorization is advantageous when exposure is difficult and many surgeons believe it is easier and more efficient,” said Dr. Lager, who presented her findings at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. Opposition to uterine exteriorization centers on concerns about hemodynamic instability, possible trauma to the uterine structures, and the potential for increased nausea, she said.

In her double-blinded, randomized trial, Dr. Lager found no difference between the two techniques in hemodynamic stability and estimated blood loss, although the intraabdominal technique was associated with a slightly longer operative time. “However, the difference was 7 minutes from skin [incision] to skin [closure] and 1 minute for uterine closure, so one could argue whether this is actually clinically significant,” she commented.

In terms of nausea, measured on a visual analog scale (VAS) ranging from 0 to 10, with 0 representing no nausea, mean nausea scores were considerably less in the 35 patients randomized to intraabdominal repair (2.3), compared with the 36 who received external repairs (4.6), she said. In addition, the rate of moderate to severe nausea was significantly lower in the intraabdominal group (35% vs. 67%). The intraabdominal group also used fewer antiemetics (18% vs. 23%) although this was not statistically significant, and VAS pain scores also showed a nonsignificant trend favoring the intraabdominal group, Dr. Lager said.

“Nausea is one of the most common concerns during cesarean delivery, second only to pain, and can interfere with uterine repair” if the patient is retching, she said, noting that according to an informal review at her hospital, 40% of women are pretreated or require treatment for nausea intraoperatively.

BANFF, ALTA. — Most obstetric anesthesia malpractice claims for maternal death or brain damage stem from block-related cardiac arrest, primarily caused by inadvertant and unrecognized intrathecal injections, according to an analysis of data from the American Society of Anesthesiologists Closed Claims Project over the last decade.

Careful spinal/epidural placement, both test and incremental dosing, and meticulous management of regional anesthetics would not only reduce this risk but also might reduce claims for more minor injuries, “which are still a very major part of litigation,” said Jo Davies of the department of anesthesiology at the University of Washington Medical Center in Seattle.

The study, which she presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, analyzed a total of 255 claims associated with obstetric regional anesthesia. “The database contains information on closed anesthesia malpractice claims from 35 insurance companies, which cover about 60% of all anesthesiologists in the United States,” she explained.

Out of the 255 claims, the study focused on those associated with maternal death (21), brain damage (15), emotional distress (26), and pain during delivery/surgery (21). The rest of the claims focused on nerve damage, headache, and backache, she said. “As one might expect, payments were most frequently made for the severe and permanent injuries of maternal death and brain damage—with a much lower rate of payment for minor injuries.”

Overall, in more than 50% of cases, anesthetic management met the standard of care, she said. However, care was found to be substandard in more than 60% of brain damage cases.

Claims for emotional distress and for pain during delivery/surgery sometimes overlapped, with patients suing for both. Inadequate block was the only contributing factor in claims for pain during surgery or delivery, with 95% resulting from cesarean rather than vaginal deliveries, she said. But inadequate block also accounted for 31% of emotional distress claims.

“Although some women vehemently refused conversion to general anesthesia and still sued, what is more disturbing are those cases where conversion to general anesthesia was either delayed or never happened—and one case where there was no verification of adequate analgesia prior to incision,” she said.

Other factors that caused emotional distress were high block causing respiratory distress and conversion to general anesthesia (15%), accidental dural puncture (15%), and unprofessional behavior (8%).

Among emotional distress claims, care was adequate in 75% of cases and payment was made in only 25%.

However, among the claims for pain, care was questionable or inadequate in nearly half because of delayed conversion or failure to convert to general anesthesia, and payment was made in 71% of these claims.

Professional conduct, the provision of realistic expectations, and education regarding the risks associated with obstetric anesthesia “may minimize the number of patients unhappy with their obstetric experience using malpractice litigation as a means of emotional vindication,” noted Ms. Davies.

BANFF, ALTA. — Most obstetric anesthesia malpractice claims for maternal death or brain damage stem from block-related cardiac arrest, primarily caused by inadvertant and unrecognized intrathecal injections, according to an analysis of data from the American Society of Anesthesiologists Closed Claims Project over the last decade.

Careful spinal/epidural placement, both test and incremental dosing, and meticulous management of regional anesthetics would not only reduce this risk but also might reduce claims for more minor injuries, “which are still a very major part of litigation,” said Jo Davies of the department of anesthesiology at the University of Washington Medical Center in Seattle.

The study, which she presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, analyzed a total of 255 claims associated with obstetric regional anesthesia. “The database contains information on closed anesthesia malpractice claims from 35 insurance companies, which cover about 60% of all anesthesiologists in the United States,” she explained.

Out of the 255 claims, the study focused on those associated with maternal death (21), brain damage (15), emotional distress (26), and pain during delivery/surgery (21). The rest of the claims focused on nerve damage, headache, and backache, she said. “As one might expect, payments were most frequently made for the severe and permanent injuries of maternal death and brain damage—with a much lower rate of payment for minor injuries.”

Overall, in more than 50% of cases, anesthetic management met the standard of care, she said. However, care was found to be substandard in more than 60% of brain damage cases.

Claims for emotional distress and for pain during delivery/surgery sometimes overlapped, with patients suing for both. Inadequate block was the only contributing factor in claims for pain during surgery or delivery, with 95% resulting from cesarean rather than vaginal deliveries, she said. But inadequate block also accounted for 31% of emotional distress claims.

“Although some women vehemently refused conversion to general anesthesia and still sued, what is more disturbing are those cases where conversion to general anesthesia was either delayed or never happened—and one case where there was no verification of adequate analgesia prior to incision,” she said.

Other factors that caused emotional distress were high block causing respiratory distress and conversion to general anesthesia (15%), accidental dural puncture (15%), and unprofessional behavior (8%).

Among emotional distress claims, care was adequate in 75% of cases and payment was made in only 25%.

However, among the claims for pain, care was questionable or inadequate in nearly half because of delayed conversion or failure to convert to general anesthesia, and payment was made in 71% of these claims.

Professional conduct, the provision of realistic expectations, and education regarding the risks associated with obstetric anesthesia “may minimize the number of patients unhappy with their obstetric experience using malpractice litigation as a means of emotional vindication,” noted Ms. Davies.

BANFF, ALTA. — Most obstetric anesthesia malpractice claims for maternal death or brain damage stem from block-related cardiac arrest, primarily caused by inadvertant and unrecognized intrathecal injections, according to an analysis of data from the American Society of Anesthesiologists Closed Claims Project over the last decade.

Careful spinal/epidural placement, both test and incremental dosing, and meticulous management of regional anesthetics would not only reduce this risk but also might reduce claims for more minor injuries, “which are still a very major part of litigation,” said Jo Davies of the department of anesthesiology at the University of Washington Medical Center in Seattle.

The study, which she presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, analyzed a total of 255 claims associated with obstetric regional anesthesia. “The database contains information on closed anesthesia malpractice claims from 35 insurance companies, which cover about 60% of all anesthesiologists in the United States,” she explained.

Out of the 255 claims, the study focused on those associated with maternal death (21), brain damage (15), emotional distress (26), and pain during delivery/surgery (21). The rest of the claims focused on nerve damage, headache, and backache, she said. “As one might expect, payments were most frequently made for the severe and permanent injuries of maternal death and brain damage—with a much lower rate of payment for minor injuries.”

Overall, in more than 50% of cases, anesthetic management met the standard of care, she said. However, care was found to be substandard in more than 60% of brain damage cases.

Claims for emotional distress and for pain during delivery/surgery sometimes overlapped, with patients suing for both. Inadequate block was the only contributing factor in claims for pain during surgery or delivery, with 95% resulting from cesarean rather than vaginal deliveries, she said. But inadequate block also accounted for 31% of emotional distress claims.

“Although some women vehemently refused conversion to general anesthesia and still sued, what is more disturbing are those cases where conversion to general anesthesia was either delayed or never happened—and one case where there was no verification of adequate analgesia prior to incision,” she said.

Other factors that caused emotional distress were high block causing respiratory distress and conversion to general anesthesia (15%), accidental dural puncture (15%), and unprofessional behavior (8%).

Among emotional distress claims, care was adequate in 75% of cases and payment was made in only 25%.

However, among the claims for pain, care was questionable or inadequate in nearly half because of delayed conversion or failure to convert to general anesthesia, and payment was made in 71% of these claims.

Professional conduct, the provision of realistic expectations, and education regarding the risks associated with obstetric anesthesia “may minimize the number of patients unhappy with their obstetric experience using malpractice litigation as a means of emotional vindication,” noted Ms. Davies.

TORONTO — Cognitive impairment in childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, Svetlana Lvovich, D.O., reported in a poster at the annual meeting of the Pediatric Academic Societies.

The pilot study included 10 patients with SLE, 5 of whom had cognitive impairment (CI) and 5 of whom did not. Patients completed three tasks during functional magnetic resonance imaging (fMRI) designed to evaluate attention, working memory, and language processing. “They need to recruit more neurons to do the task,” said Dr. Lvovich in an interview.

The preferred method for diagnosing CI in SLE patients is neuropsychiatric testing, which is time consuming and requires extensive training, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center. In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, “suggesting that SLE-specific processes contribute to CI rather than the long-term use of steroids,” she noted. “However, to determine this, we will need to look at patients who are on steroids but don't have SLE.”

“We think fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

TORONTO — Cognitive impairment in childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, Svetlana Lvovich, D.O., reported in a poster at the annual meeting of the Pediatric Academic Societies.

The pilot study included 10 patients with SLE, 5 of whom had cognitive impairment (CI) and 5 of whom did not. Patients completed three tasks during functional magnetic resonance imaging (fMRI) designed to evaluate attention, working memory, and language processing. “They need to recruit more neurons to do the task,” said Dr. Lvovich in an interview.

The preferred method for diagnosing CI in SLE patients is neuropsychiatric testing, which is time consuming and requires extensive training, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center. In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, “suggesting that SLE-specific processes contribute to CI rather than the long-term use of steroids,” she noted. “However, to determine this, we will need to look at patients who are on steroids but don't have SLE.”

“We think fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

TORONTO — Cognitive impairment in childhood-onset systemic lupus erythematosus can be identified with functional magnetic resonance imaging, Svetlana Lvovich, D.O., reported in a poster at the annual meeting of the Pediatric Academic Societies.

The pilot study included 10 patients with SLE, 5 of whom had cognitive impairment (CI) and 5 of whom did not. Patients completed three tasks during functional magnetic resonance imaging (fMRI) designed to evaluate attention, working memory, and language processing. “They need to recruit more neurons to do the task,” said Dr. Lvovich in an interview.

The preferred method for diagnosing CI in SLE patients is neuropsychiatric testing, which is time consuming and requires extensive training, said Dr. Lvovich of the Cincinnati Children's Hospital Medical Center. In contrast, fMRI is quick and easy to perform.

There also were subtle fMRI differences seen between SLE patients with normal cognition, compared with healthy controls, “suggesting that SLE-specific processes contribute to CI rather than the long-term use of steroids,” she noted. “However, to determine this, we will need to look at patients who are on steroids but don't have SLE.”

“We think fMRI may be useful to investigate and identify cortical roots of cognitive impairment in children with SLE,” she concluded.

MONTREAL — U.S. plans for an influenza virus pandemic should include a strong recommendation for bacterial pneumonia vaccination, as this measure has been shown to reduce influenza mortality by up to 50%, said Dr. Keith Klugman.

“Among the 18 fundamental points in the U.S. pandemic plan, there is little mention of bacterial vaccines. I believe their role is significant and has not been considered up until now,” he said at an international conference on community-acquired pneumonia.

Although the influenza virus alone can be fatal, the risk of death is greater with secondary pneumococcal infection, said Dr. Klugman, professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University, Atlanta.

“The combination of bacterial superinfection and influenza is highly fatal. It's a huge problem, and it's not a small part of influenza mortality and morbidity,” he said in an interview.

Evidence that pneumococcal infection played a major role in the 1918 influenza pandemic “is substantial, but seems to have been forgotten,” Dr. Klugman recently wrote in a letter to the editor (Science 2007;316:49–50).

He cited historical evidence of culturable pneumococci in the blood of at least half of the survivors and victims of influenza in two studies (Br. Med. J. 1919;1:3–5; JAMA 1918;71:1735).

And a randomized, controlled trial by Dr. Klugman and his colleagues has shown that, in children, vaccination against the pneumococcal bacteria results in a 31% decrease in pneumonias associated with respiratory viruses (Nat. Med. 2004;10:811–3).

“Because of the vaccine, they are not getting the superinfection that brings them to the hospital,” he said at the meeting, which was sponsored by the International Society of Chemotherapy. “I think people have known for years that there can be bacterial superinfections with influenza, but they just didn't realize how common they were and how much of a role they play.”

The 23-valent pneumococcal polysaccharide vaccine (PPV 23) is currently recommended in adults older than 65 years, but giving the 7-valent pneumococcal conjugate vaccine (PCV 7) to children is more protective against bacterial pneumonia in the adult population, he said.

Data from the Centers for Disease Control and Prevention show that adult infections with the seven pneumococcal strains covered in the children's vaccine have decreased, while infections from the other 16 strains covered by the adult vaccine have increased.

“The burden of disease in adults has been impacted more by giving the conjugate vaccine to children than by giving the 23-valent vaccine to adults,” Dr. Klugman said.

This has led some investigators to ask whether adults might benefit by being immunized using the children's conjugate vaccine. (See box below.)

Also, a new study (Lancet 2007;369:1179–86) offers the first evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said.

Improving pneumococcal vaccine coverage in children could result in major reductions in infection across all ages, he said.

“Only about 60% of kids currently get the full four doses of the conjugate vaccine, and it's that fourth dose that induces the full immunity and stops transmission, so we need to do a much better job of immunizing kids.”

Giving Adults the Children's Conjugate Vaccine May Backfire, Researchers Say

Is there a role for giving the children's conjugate vaccine to adults?

A recent study suggested that it may not be as simple as that (Vaccine 2007;25:4029–37). Immunogenicity among elderly patients (aged 70–79 years) who were given the children's dose of conjugate vaccine was “nothing to get overly excited about,” Dr. Klugman said. “Perhaps the dose designed for a primary response in kids is not enough for adults,” he suggested.

And a study presented at the 2006 International Symposium on Pneumococci and Pneumococcal Diseases by Dr. Andrés de Roux, of the Universitat Autònoma de Barcelona, and colleagues suggested that the administration of the children's conjugate vaccine to elderly patients within 1 year of giving them the polysaccharide vaccine could actually suppress immunity.

“It seems the adult vaccine interferes with the response to the conjugate, which is a concern, because it means we can't simply give the conjugate to people who have previously had the [23-valent vaccine]. There will have to be a strategy, and it seems that certainly the conjugate needs to be given before the 23-valent,” Dr. Klugman said.

Dr. Klugman said that in his opinion, a new conjugate vaccine, with coverage of more strains than the current one, will eventually replace the PPV 23 for adults.

MONTREAL — U.S. plans for an influenza virus pandemic should include a strong recommendation for bacterial pneumonia vaccination, as this measure has been shown to reduce influenza mortality by up to 50%, said Dr. Keith Klugman.

“Among the 18 fundamental points in the U.S. pandemic plan, there is little mention of bacterial vaccines. I believe their role is significant and has not been considered up until now,” he said at an international conference on community-acquired pneumonia.

Although the influenza virus alone can be fatal, the risk of death is greater with secondary pneumococcal infection, said Dr. Klugman, professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University, Atlanta.

“The combination of bacterial superinfection and influenza is highly fatal. It's a huge problem, and it's not a small part of influenza mortality and morbidity,” he said in an interview.

Evidence that pneumococcal infection played a major role in the 1918 influenza pandemic “is substantial, but seems to have been forgotten,” Dr. Klugman recently wrote in a letter to the editor (Science 2007;316:49–50).

He cited historical evidence of culturable pneumococci in the blood of at least half of the survivors and victims of influenza in two studies (Br. Med. J. 1919;1:3–5; JAMA 1918;71:1735).

And a randomized, controlled trial by Dr. Klugman and his colleagues has shown that, in children, vaccination against the pneumococcal bacteria results in a 31% decrease in pneumonias associated with respiratory viruses (Nat. Med. 2004;10:811–3).

“Because of the vaccine, they are not getting the superinfection that brings them to the hospital,” he said at the meeting, which was sponsored by the International Society of Chemotherapy. “I think people have known for years that there can be bacterial superinfections with influenza, but they just didn't realize how common they were and how much of a role they play.”

The 23-valent pneumococcal polysaccharide vaccine (PPV 23) is currently recommended in adults older than 65 years, but giving the 7-valent pneumococcal conjugate vaccine (PCV 7) to children is more protective against bacterial pneumonia in the adult population, he said.

Data from the Centers for Disease Control and Prevention show that adult infections with the seven pneumococcal strains covered in the children's vaccine have decreased, while infections from the other 16 strains covered by the adult vaccine have increased.

“The burden of disease in adults has been impacted more by giving the conjugate vaccine to children than by giving the 23-valent vaccine to adults,” Dr. Klugman said.

This has led some investigators to ask whether adults might benefit by being immunized using the children's conjugate vaccine. (See box below.)

Also, a new study (Lancet 2007;369:1179–86) offers the first evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said.

Improving pneumococcal vaccine coverage in children could result in major reductions in infection across all ages, he said.

“Only about 60% of kids currently get the full four doses of the conjugate vaccine, and it's that fourth dose that induces the full immunity and stops transmission, so we need to do a much better job of immunizing kids.”

Giving Adults the Children's Conjugate Vaccine May Backfire, Researchers Say

Is there a role for giving the children's conjugate vaccine to adults?

A recent study suggested that it may not be as simple as that (Vaccine 2007;25:4029–37). Immunogenicity among elderly patients (aged 70–79 years) who were given the children's dose of conjugate vaccine was “nothing to get overly excited about,” Dr. Klugman said. “Perhaps the dose designed for a primary response in kids is not enough for adults,” he suggested.

And a study presented at the 2006 International Symposium on Pneumococci and Pneumococcal Diseases by Dr. Andrés de Roux, of the Universitat Autònoma de Barcelona, and colleagues suggested that the administration of the children's conjugate vaccine to elderly patients within 1 year of giving them the polysaccharide vaccine could actually suppress immunity.

“It seems the adult vaccine interferes with the response to the conjugate, which is a concern, because it means we can't simply give the conjugate to people who have previously had the [23-valent vaccine]. There will have to be a strategy, and it seems that certainly the conjugate needs to be given before the 23-valent,” Dr. Klugman said.

Dr. Klugman said that in his opinion, a new conjugate vaccine, with coverage of more strains than the current one, will eventually replace the PPV 23 for adults.

MONTREAL — U.S. plans for an influenza virus pandemic should include a strong recommendation for bacterial pneumonia vaccination, as this measure has been shown to reduce influenza mortality by up to 50%, said Dr. Keith Klugman.

“Among the 18 fundamental points in the U.S. pandemic plan, there is little mention of bacterial vaccines. I believe their role is significant and has not been considered up until now,” he said at an international conference on community-acquired pneumonia.

Although the influenza virus alone can be fatal, the risk of death is greater with secondary pneumococcal infection, said Dr. Klugman, professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University, Atlanta.

“The combination of bacterial superinfection and influenza is highly fatal. It's a huge problem, and it's not a small part of influenza mortality and morbidity,” he said in an interview.

Evidence that pneumococcal infection played a major role in the 1918 influenza pandemic “is substantial, but seems to have been forgotten,” Dr. Klugman recently wrote in a letter to the editor (Science 2007;316:49–50).

He cited historical evidence of culturable pneumococci in the blood of at least half of the survivors and victims of influenza in two studies (Br. Med. J. 1919;1:3–5; JAMA 1918;71:1735).

And a randomized, controlled trial by Dr. Klugman and his colleagues has shown that, in children, vaccination against the pneumococcal bacteria results in a 31% decrease in pneumonias associated with respiratory viruses (Nat. Med. 2004;10:811–3).

“Because of the vaccine, they are not getting the superinfection that brings them to the hospital,” he said at the meeting, which was sponsored by the International Society of Chemotherapy. “I think people have known for years that there can be bacterial superinfections with influenza, but they just didn't realize how common they were and how much of a role they play.”

The 23-valent pneumococcal polysaccharide vaccine (PPV 23) is currently recommended in adults older than 65 years, but giving the 7-valent pneumococcal conjugate vaccine (PCV 7) to children is more protective against bacterial pneumonia in the adult population, he said.

Data from the Centers for Disease Control and Prevention show that adult infections with the seven pneumococcal strains covered in the children's vaccine have decreased, while infections from the other 16 strains covered by the adult vaccine have increased.

“The burden of disease in adults has been impacted more by giving the conjugate vaccine to children than by giving the 23-valent vaccine to adults,” Dr. Klugman said.

This has led some investigators to ask whether adults might benefit by being immunized using the children's conjugate vaccine. (See box below.)

Also, a new study (Lancet 2007;369:1179–86) offers the first evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said.

Improving pneumococcal vaccine coverage in children could result in major reductions in infection across all ages, he said.

“Only about 60% of kids currently get the full four doses of the conjugate vaccine, and it's that fourth dose that induces the full immunity and stops transmission, so we need to do a much better job of immunizing kids.”

Giving Adults the Children's Conjugate Vaccine May Backfire, Researchers Say

Is there a role for giving the children's conjugate vaccine to adults?

A recent study suggested that it may not be as simple as that (Vaccine 2007;25:4029–37). Immunogenicity among elderly patients (aged 70–79 years) who were given the children's dose of conjugate vaccine was “nothing to get overly excited about,” Dr. Klugman said. “Perhaps the dose designed for a primary response in kids is not enough for adults,” he suggested.

And a study presented at the 2006 International Symposium on Pneumococci and Pneumococcal Diseases by Dr. Andrés de Roux, of the Universitat Autònoma de Barcelona, and colleagues suggested that the administration of the children's conjugate vaccine to elderly patients within 1 year of giving them the polysaccharide vaccine could actually suppress immunity.

“It seems the adult vaccine interferes with the response to the conjugate, which is a concern, because it means we can't simply give the conjugate to people who have previously had the [23-valent vaccine]. There will have to be a strategy, and it seems that certainly the conjugate needs to be given before the 23-valent,” Dr. Klugman said.

Dr. Klugman said that in his opinion, a new conjugate vaccine, with coverage of more strains than the current one, will eventually replace the PPV 23 for adults.