Kate Johnson

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this [will be] a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview.

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007; doi:10.1164/rccm.200603–350OC).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common.

'Right now all we can do is base our treatment decisions on an empiric approach.' DR. FILE

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this [will be] a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview.

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007; doi:10.1164/rccm.200603–350OC).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common.

'Right now all we can do is base our treatment decisions on an empiric approach.' DR. FILE

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this [will be] a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview.

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007; doi:10.1164/rccm.200603–350OC).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common.

'Right now all we can do is base our treatment decisions on an empiric approach.' DR. FILE

MONTREAL — Is there a role for giving the children's conjugate vaccine to adults, asked Dr. Keith Klugman at an international conference on community-acquired pneumonia.

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,” said Dr. Klugman, a professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University in Atlanta.

“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 pneumococcal polysaccharide vaccine (PPV 23)]. 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.

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,” said Dr. Klugman.

A new study (Lancet 2007;369:1179–86) offers evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said at the conference, sponsored by the International Society of Chemotherapy.

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

MONTREAL — Is there a role for giving the children's conjugate vaccine to adults, asked Dr. Keith Klugman at an international conference on community-acquired pneumonia.

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,” said Dr. Klugman, a professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University in Atlanta.

“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 pneumococcal polysaccharide vaccine (PPV 23)]. 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.

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,” said Dr. Klugman.

A new study (Lancet 2007;369:1179–86) offers evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said at the conference, sponsored by the International Society of Chemotherapy.

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

MONTREAL — Is there a role for giving the children's conjugate vaccine to adults, asked Dr. Keith Klugman at an international conference on community-acquired pneumonia.

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,” said Dr. Klugman, a professor of infectious diseases and the William H. Foege Chair of Global Health at Emory University in Atlanta.

“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 pneumococcal polysaccharide vaccine (PPV 23)]. 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.

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,” said Dr. Klugman.

A new study (Lancet 2007;369:1179–86) offers evidence that vaccinating children protects adults against all pneumococcal pneumonia, not just bacteremic pneumococcal pneumonia, he said at the conference, sponsored by the International Society of Chemotherapy.

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

MONTREAL — Influenza vaccines and antiviral drugs greatly reduce the incidence of and mortality associated with community-acquired pneumonia, but they are grossly underutilized, according to Dr. Grant Stiver, professor of medicine at the University of British Columbia, Vancouver.

“We are not optimizing the management of influenza by far—largely because of costs and political unwillingness to put out money,” he said at an international conference on community-acquired pneumonia (CAP). “We are the ones who influence policy. … We need to do a better job at campaigning for improved resources to reduce the morbidity and mortality due to influenza because it's quite clear that we're just not doing enough.”

Until now, influenza prevention has focused on so-called high-risk groups, but there is no reason why the net shouldn't be widened to include everyone, Dr. Stiver said. During the 2003–2004 influenza season, half of the 153 influenza-associated deaths among children in the United States were in those with no high-risk conditions (N. Engl. J. Med. 2005;353:2559–67).

“These were your normal children or grandchildren,” he said, adding that 70% of the deaths resulted from respiratory infection, and 47% of these were from confirmed CAP. “Pneumonia is a scary thing for the public, but influenza is not. Influenza is something that the public can trivialize until a member of their family dies from pneumonia. So if we show we can actually prevent pneumonia with the optimization of influenza vaccine and antivirals, we can probably get better public acceptance.”

Dr. Stiver said that to increase vaccination rates, it may be time to put more pressure on target groups such as health care workers. “We should make vaccination a condition of employment for health care workers, and if they don't want it, they can't work in a health care institution. We can play hardball and demand this,” he said. Essential service workers who are designated as first priority for antiviral prophylaxis in the event of a pandemic should be denied the drugs if they have not been previously vaccinated, he suggested at the meeting, which was sponsored by the International Society of Chemotherapy.

MONTREAL — Influenza vaccines and antiviral drugs greatly reduce the incidence of and mortality associated with community-acquired pneumonia, but they are grossly underutilized, according to Dr. Grant Stiver, professor of medicine at the University of British Columbia, Vancouver.

“We are not optimizing the management of influenza by far—largely because of costs and political unwillingness to put out money,” he said at an international conference on community-acquired pneumonia (CAP). “We are the ones who influence policy. … We need to do a better job at campaigning for improved resources to reduce the morbidity and mortality due to influenza because it's quite clear that we're just not doing enough.”

Until now, influenza prevention has focused on so-called high-risk groups, but there is no reason why the net shouldn't be widened to include everyone, Dr. Stiver said. During the 2003–2004 influenza season, half of the 153 influenza-associated deaths among children in the United States were in those with no high-risk conditions (N. Engl. J. Med. 2005;353:2559–67).

“These were your normal children or grandchildren,” he said, adding that 70% of the deaths resulted from respiratory infection, and 47% of these were from confirmed CAP. “Pneumonia is a scary thing for the public, but influenza is not. Influenza is something that the public can trivialize until a member of their family dies from pneumonia. So if we show we can actually prevent pneumonia with the optimization of influenza vaccine and antivirals, we can probably get better public acceptance.”

Dr. Stiver said that to increase vaccination rates, it may be time to put more pressure on target groups such as health care workers. “We should make vaccination a condition of employment for health care workers, and if they don't want it, they can't work in a health care institution. We can play hardball and demand this,” he said. Essential service workers who are designated as first priority for antiviral prophylaxis in the event of a pandemic should be denied the drugs if they have not been previously vaccinated, he suggested at the meeting, which was sponsored by the International Society of Chemotherapy.

MONTREAL — Influenza vaccines and antiviral drugs greatly reduce the incidence of and mortality associated with community-acquired pneumonia, but they are grossly underutilized, according to Dr. Grant Stiver, professor of medicine at the University of British Columbia, Vancouver.

“We are not optimizing the management of influenza by far—largely because of costs and political unwillingness to put out money,” he said at an international conference on community-acquired pneumonia (CAP). “We are the ones who influence policy. … We need to do a better job at campaigning for improved resources to reduce the morbidity and mortality due to influenza because it's quite clear that we're just not doing enough.”

Until now, influenza prevention has focused on so-called high-risk groups, but there is no reason why the net shouldn't be widened to include everyone, Dr. Stiver said. During the 2003–2004 influenza season, half of the 153 influenza-associated deaths among children in the United States were in those with no high-risk conditions (N. Engl. J. Med. 2005;353:2559–67).

“These were your normal children or grandchildren,” he said, adding that 70% of the deaths resulted from respiratory infection, and 47% of these were from confirmed CAP. “Pneumonia is a scary thing for the public, but influenza is not. Influenza is something that the public can trivialize until a member of their family dies from pneumonia. So if we show we can actually prevent pneumonia with the optimization of influenza vaccine and antivirals, we can probably get better public acceptance.”

Dr. Stiver said that to increase vaccination rates, it may be time to put more pressure on target groups such as health care workers. “We should make vaccination a condition of employment for health care workers, and if they don't want it, they can't work in a health care institution. We can play hardball and demand this,” he said. Essential service workers who are designated as first priority for antiviral prophylaxis in the event of a pandemic should be denied the drugs if they have not been previously vaccinated, he suggested at the meeting, which was sponsored by the International Society of Chemotherapy.

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), citing 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 that 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.”

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), citing 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 that 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.”

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), citing 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 that 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.”

MONTREAL — The high mortality in community-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus may be largely due to Panton-Valentine leukocidin toxin, said Dr. Ian Gould, consultant microbiologist at the University of Aberdeen (Scotland).

Thus, efforts to control the infection should probably focus on the toxin as well as the bacteria, Dr. Gould said at an international conference on community-acquired pneumonia. “Even if the antibiotics can kill the bug, the toxin's still there and that's what's doing the damage,” he said in an interview at the meeting.

Panton-Valentine leukocidin (PVL) toxin is produced mostly by community-acquired, as opposed to hospital-acquired, strains of methicillin-resistant S. aureus (MRSA). And the prevalence is increasing, Dr. Gould said.

“Clearly, there have been big changes in the epidemiology of community-acquired MRSA, and now there are quite a few epidemic strains that produce PVL,” he said. In fact, according to a recent report from the Centers for Disease Control, the majority of reported community-acquired MRSA infections are PVL-producing strains (MMWR 2007;56:325–9; see story at left.) Yet although most of these infections involve skin and soft tissue and are “relatively mild,” according to Dr. Gould, “more and more commonly, we're seeing very severe respiratory disease.” In the recent CDC report of 10 cases of MRSA-associated community acquired pneumonia (CAP), all isolates were positive for PVL toxin.

“This is an organism that causes severe pneumonia,” said Dr. Coleman Rotstein, who also presented at the meeting, which was sponsored by the International Society of Chemotherapy. The key features of CAP caused by MRSA are empyema and necrotizing pneumonia, said Dr. Rotstein, professor of medicine at McMaster University, Hamilton, Ont.

He and other experts at the meeting agreed that treatment options are limited.

“When it comes to treatment, we are standing in the dark, with a case mortality in the published literature of around 75%,” Dr. Gould said.

“For these new MRSA CAP etiologies, the present arsenal of antibiotics is unfortunately insufficient,” said Dr. Ethan Rubenstein, who also presented at the meeting. He is professor and head of infectious diseases at the University of Manitoba, Winnipeg.

According to Dr. Gould, high-dose clindamycin or linezolid are good options not only for their antibacterial effects but also because of their potential ability to lower PVL production. IV immunoglobulin is also well recognized as an adjunct, he said. In addition, gentamicin is indicated for patients who are bacteremic.

“We haven't seen the end of this story by any means—this is a highly adaptable, rapidly developing organism,” Dr. Gould said. “I have to say things are going to get worse here before they get better.”

MONTREAL — The high mortality in community-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus may be largely due to Panton-Valentine leukocidin toxin, said Dr. Ian Gould, consultant microbiologist at the University of Aberdeen (Scotland).

Thus, efforts to control the infection should probably focus on the toxin as well as the bacteria, Dr. Gould said at an international conference on community-acquired pneumonia. “Even if the antibiotics can kill the bug, the toxin's still there and that's what's doing the damage,” he said in an interview at the meeting.

Panton-Valentine leukocidin (PVL) toxin is produced mostly by community-acquired, as opposed to hospital-acquired, strains of methicillin-resistant S. aureus (MRSA). And the prevalence is increasing, Dr. Gould said.

“Clearly, there have been big changes in the epidemiology of community-acquired MRSA, and now there are quite a few epidemic strains that produce PVL,” he said. In fact, according to a recent report from the Centers for Disease Control, the majority of reported community-acquired MRSA infections are PVL-producing strains (MMWR 2007;56:325–9; see story at left.) Yet although most of these infections involve skin and soft tissue and are “relatively mild,” according to Dr. Gould, “more and more commonly, we're seeing very severe respiratory disease.” In the recent CDC report of 10 cases of MRSA-associated community acquired pneumonia (CAP), all isolates were positive for PVL toxin.

“This is an organism that causes severe pneumonia,” said Dr. Coleman Rotstein, who also presented at the meeting, which was sponsored by the International Society of Chemotherapy. The key features of CAP caused by MRSA are empyema and necrotizing pneumonia, said Dr. Rotstein, professor of medicine at McMaster University, Hamilton, Ont.

He and other experts at the meeting agreed that treatment options are limited.

“When it comes to treatment, we are standing in the dark, with a case mortality in the published literature of around 75%,” Dr. Gould said.

“For these new MRSA CAP etiologies, the present arsenal of antibiotics is unfortunately insufficient,” said Dr. Ethan Rubenstein, who also presented at the meeting. He is professor and head of infectious diseases at the University of Manitoba, Winnipeg.

According to Dr. Gould, high-dose clindamycin or linezolid are good options not only for their antibacterial effects but also because of their potential ability to lower PVL production. IV immunoglobulin is also well recognized as an adjunct, he said. In addition, gentamicin is indicated for patients who are bacteremic.

“We haven't seen the end of this story by any means—this is a highly adaptable, rapidly developing organism,” Dr. Gould said. “I have to say things are going to get worse here before they get better.”

MONTREAL — The high mortality in community-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus may be largely due to Panton-Valentine leukocidin toxin, said Dr. Ian Gould, consultant microbiologist at the University of Aberdeen (Scotland).

Thus, efforts to control the infection should probably focus on the toxin as well as the bacteria, Dr. Gould said at an international conference on community-acquired pneumonia. “Even if the antibiotics can kill the bug, the toxin's still there and that's what's doing the damage,” he said in an interview at the meeting.

Panton-Valentine leukocidin (PVL) toxin is produced mostly by community-acquired, as opposed to hospital-acquired, strains of methicillin-resistant S. aureus (MRSA). And the prevalence is increasing, Dr. Gould said.

“Clearly, there have been big changes in the epidemiology of community-acquired MRSA, and now there are quite a few epidemic strains that produce PVL,” he said. In fact, according to a recent report from the Centers for Disease Control, the majority of reported community-acquired MRSA infections are PVL-producing strains (MMWR 2007;56:325–9; see story at left.) Yet although most of these infections involve skin and soft tissue and are “relatively mild,” according to Dr. Gould, “more and more commonly, we're seeing very severe respiratory disease.” In the recent CDC report of 10 cases of MRSA-associated community acquired pneumonia (CAP), all isolates were positive for PVL toxin.

“This is an organism that causes severe pneumonia,” said Dr. Coleman Rotstein, who also presented at the meeting, which was sponsored by the International Society of Chemotherapy. The key features of CAP caused by MRSA are empyema and necrotizing pneumonia, said Dr. Rotstein, professor of medicine at McMaster University, Hamilton, Ont.

He and other experts at the meeting agreed that treatment options are limited.

“When it comes to treatment, we are standing in the dark, with a case mortality in the published literature of around 75%,” Dr. Gould said.

“For these new MRSA CAP etiologies, the present arsenal of antibiotics is unfortunately insufficient,” said Dr. Ethan Rubenstein, who also presented at the meeting. He is professor and head of infectious diseases at the University of Manitoba, Winnipeg.

According to Dr. Gould, high-dose clindamycin or linezolid are good options not only for their antibacterial effects but also because of their potential ability to lower PVL production. IV immunoglobulin is also well recognized as an adjunct, he said. In addition, gentamicin is indicated for patients who are bacteremic.

“We haven't seen the end of this story by any means—this is a highly adaptable, rapidly developing organism,” Dr. Gould said. “I have to say things are going to get worse here before they get better.”

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this is a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview. “If you tell a patient, 'I am going to reduce your fatigue and malaise by 6 days,' that's important. It may not affect mortality at all, but if it can significantly reduce morbidity, I would argue that's a significant benefit.”

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007 [Epub doi:10.1164/rccm.200603–350OC]).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. “The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common than pneumonia. The Europeans may be overtreating a lot of viral bronchitis.”

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this is a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview. “If you tell a patient, 'I am going to reduce your fatigue and malaise by 6 days,' that's important. It may not affect mortality at all, but if it can significantly reduce morbidity, I would argue that's a significant benefit.”

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007 [Epub doi:10.1164/rccm.200603–350OC]).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. “The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common than pneumonia. The Europeans may be overtreating a lot of viral bronchitis.”

MONTREAL — European and North American experts continue to disagree about the management of mild community-acquired pneumonia, with the debate centering on the overuse of wide-spectrum antibiotics.

New guidelines released jointly by the Infectious Diseases Society of America and the American Thoracic Society recommend that empiric treatment of mild CAP in previously healthy individuals should include a macrolide to cover not only the most common pathogen (Streptococcus pneumoniae) but also atypical pathogens (Clin. Infect. Dis. 2007;44 [suppl. 2]:S29–72). In contrast, European guidelines do not target atypical pathogens, recommending β-lactams as the only treatment of choice (Eur. Respir. J. 2005;26:1138–80).

“If and when we get rapid diagnostic tests [to identify specific pathogens], this is a moot point, but right now all we can do is base our treatment decisions on an empiric approach,” Dr. Thomas File, professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown, said at an international conference on community-acquired pneumonia.

European and North American experts agree that roughly 40% of mild CAP may be caused by atypical pathogens, but Europeans are prepared to ignore these pathogens in their choice of empiric therapy because these infections are usually self-resolving, said Dr. Jean-Claude Pechère, a professor of medicine at the University of Geneva.

“In this way, we can avoid a lot of antibiotic overuse,” he said in an interview. “In the context of increasing resistance, it's a big public health issue.”

Although many atypical CAP infections are self-resolving, the evidence shows that antibiotics can speed recovery, Dr. File said at the conference, sponsored by the International Society of Chemotherapy. “People get sick, and people are off work or school. If, by treating them, we can help them resolve their illness quicker, then we think it's worthwhile,” he said in an interview. “If you tell a patient, 'I am going to reduce your fatigue and malaise by 6 days,' that's important. It may not affect mortality at all, but if it can significantly reduce morbidity, I would argue that's a significant benefit.”

However, new evidence suggests coverage of atypical pathogens also may improve mortality, at least in hospitalized patients, Dr. File said. An analysis of more than 2,000 patients found that, compared with those treated only for typical pathogens, those treated with atypical coverage had decreased time to clinical stability (3.2 vs. 3.7 days), decreased length of hospital stay (6.1 vs. 7.1 days), decreased total mortality (7.0% vs. 11.1%), and decreased CAP-related mortality (3.8% vs. 6.4%) (Am. J. Respir. Crit. Care Med. 2007 [Epub doi:10.1164/rccm.200603–350OC]).

“The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens,” the authors concluded.

The atypical pathogens responsible for mild CAP include Mycoplasma pneumoniae and Chlamydia pneumoniae. Dr. Pechère and Dr. File agreed that the third atypical pathogen, Legionella, without question should be treated immediately and aggressively, because it is associated with a high mortality rate.

According to Dr. Pechère, the North American guidelines “promote overuse” of antibiotics. But Dr. File sees it differently. The IDSA/ATS guidelines underscore the necessity of a chest x-ray in the diagnosis of CAP, thus ensuring that only radiographically confirmed cases are treated. “If the decision is based on a positive chest x-ray, then we feel all those patients warrant antimicrobial therapy—because it's unlikely that they've got viral bronchitis if they've got true infiltrate.”

But this is not the scenario in Europe, he said, where x-ray confirmation is not required for the diagnosis of CAP. “The overuse of antibiotics in respiratory infection is not from overtreating pneumonia, it's from overtreating viral infections, which are much more common than pneumonia. The Europeans may be overtreating a lot of viral bronchitis.”

QUEBEC CITY — Children with chronic health conditions should be encouraged to play sports, and guidelines about physical activity in children with specific conditions will soon be available, said Dr. John Philpott, who is heading the joint effort of the Canadian Academy of Sport Medicine and the Canadian Pediatric Society.

Dr. Philpott, a pediatric sports medicine specialist at the University of Toronto, outlined conditions already discussed by the joint guideline committee, including juvenile idiopathic arthritis, hemophilia, diabetes types 1 and 2, and cystic fibrosis.

Arthritis

Children with juvenile idiopathic arthritis are prone to injury as a result of instability, muscle atrophy, and osteopenia, Dr. Philpott said at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

They might be limited by increased energy expenditure, compared with healthy children, and by joint pain, but overall, their level of aerobic fitness is determined more by the duration rather than the severity of their disease. Particular risks in this population can arise from uveitis and temporomandibular joint involvement—making eye protection and mouth guards important.

Children with systemic arthritis and those with HLA-B27-associated disease might have cardiac problems that should be carefully assessed by a pediatric cardiologist. Though more liberal attitudes toward exercise are emerging for this population in general, Dr. Philpott said limited weight-bearing activity is still recommended for children with moderate to severe disease.

Children with neck arthritis should have x-ray evaluation of their C1–C2 stability, “which may or may not affect your recommendations regarding contact or collision sports,” he said.

Hemophilia

For children with hemophilia, minimizing bleeding risk is obviously the main concern, Dr. Philpott said. These children might have pain and limited range of motion that contribute to their overall lower level of physical fitness and muscle strength, compared with healthy children. However, there is good evidence that physical fitness is beneficial in this population because it improves bone density and factor VIII levels.

“Most children with hemophilia are appropriately prophylaxed to minimize bleeding risk, but it is important that there is a care plan for the patient, parents, and coaches aimed at preventing and treating bleeds,” he said. This should include protective equipment, factor prophylaxis and replacement therapy, and icing.

Diabetes

Most children with diabetes can play any sport, with an individualized approach to blood glucose control, he said. “Hypoglycemia is of particular concern for an exercising child with this disease—particularly those with type 1 diabetes who are on insulin—although some type 2 patients are also on insulin.”

Children are more prone than adults to blood glucose variations, and exercise increases insulin sensitivity. “After exercise, overnight hypoglycemia—especially in a new diabetic—can be a grave concern, and this needs to be monitored closely.”

Medical alert bracelets are very helpful.

Blood glucose monitoring is recommended before, during, and after exercise—at least initially, Dr. Philpott said, and use of insulin pumps might be considered.

Cystic Fibrosis

Ventilation is the main issue for patients with cystic fibrosis. “Mucus plugging and bronchospasm all lead to airflow restriction and carbon dioxide retention; oxygen desaturation and cyanosis are not uncommon,” he said. Also, chronic malnutrition from malabsorption can result in decreased muscle mass and strength.

There are no absolute contraindications to sport participation for children with cystic fibrosis, although scuba diving is not recommended because of the risks of pneumothorax, said Dr. Philpott.

“These patients can have greater salt loss and dehydration during exercise, compared to their healthy peers, and flavored sodium-chloride drinks are helpful for this,” he recommended.

QUEBEC CITY — Children with chronic health conditions should be encouraged to play sports, and guidelines about physical activity in children with specific conditions will soon be available, said Dr. John Philpott, who is heading the joint effort of the Canadian Academy of Sport Medicine and the Canadian Pediatric Society.

Dr. Philpott, a pediatric sports medicine specialist at the University of Toronto, outlined conditions already discussed by the joint guideline committee, including juvenile idiopathic arthritis, hemophilia, diabetes types 1 and 2, and cystic fibrosis.

Arthritis

Children with juvenile idiopathic arthritis are prone to injury as a result of instability, muscle atrophy, and osteopenia, Dr. Philpott said at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

They might be limited by increased energy expenditure, compared with healthy children, and by joint pain, but overall, their level of aerobic fitness is determined more by the duration rather than the severity of their disease. Particular risks in this population can arise from uveitis and temporomandibular joint involvement—making eye protection and mouth guards important.

Children with systemic arthritis and those with HLA-B27-associated disease might have cardiac problems that should be carefully assessed by a pediatric cardiologist. Though more liberal attitudes toward exercise are emerging for this population in general, Dr. Philpott said limited weight-bearing activity is still recommended for children with moderate to severe disease.

Children with neck arthritis should have x-ray evaluation of their C1–C2 stability, “which may or may not affect your recommendations regarding contact or collision sports,” he said.

Hemophilia

For children with hemophilia, minimizing bleeding risk is obviously the main concern, Dr. Philpott said. These children might have pain and limited range of motion that contribute to their overall lower level of physical fitness and muscle strength, compared with healthy children. However, there is good evidence that physical fitness is beneficial in this population because it improves bone density and factor VIII levels.

“Most children with hemophilia are appropriately prophylaxed to minimize bleeding risk, but it is important that there is a care plan for the patient, parents, and coaches aimed at preventing and treating bleeds,” he said. This should include protective equipment, factor prophylaxis and replacement therapy, and icing.

Diabetes

Most children with diabetes can play any sport, with an individualized approach to blood glucose control, he said. “Hypoglycemia is of particular concern for an exercising child with this disease—particularly those with type 1 diabetes who are on insulin—although some type 2 patients are also on insulin.”

Children are more prone than adults to blood glucose variations, and exercise increases insulin sensitivity. “After exercise, overnight hypoglycemia—especially in a new diabetic—can be a grave concern, and this needs to be monitored closely.”

Medical alert bracelets are very helpful.

Blood glucose monitoring is recommended before, during, and after exercise—at least initially, Dr. Philpott said, and use of insulin pumps might be considered.

Cystic Fibrosis

Ventilation is the main issue for patients with cystic fibrosis. “Mucus plugging and bronchospasm all lead to airflow restriction and carbon dioxide retention; oxygen desaturation and cyanosis are not uncommon,” he said. Also, chronic malnutrition from malabsorption can result in decreased muscle mass and strength.

There are no absolute contraindications to sport participation for children with cystic fibrosis, although scuba diving is not recommended because of the risks of pneumothorax, said Dr. Philpott.

“These patients can have greater salt loss and dehydration during exercise, compared to their healthy peers, and flavored sodium-chloride drinks are helpful for this,” he recommended.

QUEBEC CITY — Children with chronic health conditions should be encouraged to play sports, and guidelines about physical activity in children with specific conditions will soon be available, said Dr. John Philpott, who is heading the joint effort of the Canadian Academy of Sport Medicine and the Canadian Pediatric Society.

Dr. Philpott, a pediatric sports medicine specialist at the University of Toronto, outlined conditions already discussed by the joint guideline committee, including juvenile idiopathic arthritis, hemophilia, diabetes types 1 and 2, and cystic fibrosis.

Arthritis

Children with juvenile idiopathic arthritis are prone to injury as a result of instability, muscle atrophy, and osteopenia, Dr. Philpott said at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

They might be limited by increased energy expenditure, compared with healthy children, and by joint pain, but overall, their level of aerobic fitness is determined more by the duration rather than the severity of their disease. Particular risks in this population can arise from uveitis and temporomandibular joint involvement—making eye protection and mouth guards important.

Children with systemic arthritis and those with HLA-B27-associated disease might have cardiac problems that should be carefully assessed by a pediatric cardiologist. Though more liberal attitudes toward exercise are emerging for this population in general, Dr. Philpott said limited weight-bearing activity is still recommended for children with moderate to severe disease.

Children with neck arthritis should have x-ray evaluation of their C1–C2 stability, “which may or may not affect your recommendations regarding contact or collision sports,” he said.

Hemophilia

For children with hemophilia, minimizing bleeding risk is obviously the main concern, Dr. Philpott said. These children might have pain and limited range of motion that contribute to their overall lower level of physical fitness and muscle strength, compared with healthy children. However, there is good evidence that physical fitness is beneficial in this population because it improves bone density and factor VIII levels.

“Most children with hemophilia are appropriately prophylaxed to minimize bleeding risk, but it is important that there is a care plan for the patient, parents, and coaches aimed at preventing and treating bleeds,” he said. This should include protective equipment, factor prophylaxis and replacement therapy, and icing.

Diabetes

Most children with diabetes can play any sport, with an individualized approach to blood glucose control, he said. “Hypoglycemia is of particular concern for an exercising child with this disease—particularly those with type 1 diabetes who are on insulin—although some type 2 patients are also on insulin.”

Children are more prone than adults to blood glucose variations, and exercise increases insulin sensitivity. “After exercise, overnight hypoglycemia—especially in a new diabetic—can be a grave concern, and this needs to be monitored closely.”

Medical alert bracelets are very helpful.

Blood glucose monitoring is recommended before, during, and after exercise—at least initially, Dr. Philpott said, and use of insulin pumps might be considered.

Cystic Fibrosis

Ventilation is the main issue for patients with cystic fibrosis. “Mucus plugging and bronchospasm all lead to airflow restriction and carbon dioxide retention; oxygen desaturation and cyanosis are not uncommon,” he said. Also, chronic malnutrition from malabsorption can result in decreased muscle mass and strength.

There are no absolute contraindications to sport participation for children with cystic fibrosis, although scuba diving is not recommended because of the risks of pneumothorax, said Dr. Philpott.

“These patients can have greater salt loss and dehydration during exercise, compared to their healthy peers, and flavored sodium-chloride drinks are helpful for this,” he recommended.

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack

QUEBEC CITY — Athletic patients under age 30 years with a first-time shoulder dislocation might benefit from early surgical repair rather than conservative therapy, said Dr. Robert McCormack at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“The [standard] is to keep patients in a sling for a few weeks and send them to physiotherapy. But the evidence is that most will redislocate. … In a select group of athletic people, there is evidence to support a more aggressive approach,” said Dr. Robert McCormack, an orthopedic surgeon at the University of British Columbia, Vancouver, in an interview. Collision and contact sports such as rugby and football, as well as skiing and rock climbing, present high risk for dislocation, he noted.

Dr. McCormack, who is also chief medical officer for the Canadian Olympic Team, outlined factors to consider when selecting candidates for early surgery. “I wouldn't go so far as to say that everyone needs to have primary surgical stabilization. What we can say is that studies have shown that in high-demand people, who are young and have risk of recurrence, we can change that natural history.”

A Cochrane review of five studies suggests a fivefold greater risk of recurrent instability in young, active patients treated conservatively, compared with surgically (Cochrane Database Syst. Rev. 2004;[1]:CD004325). Similarly, a 10-year follow-up of first-time shoulder dislocations randomized to conservative or surgical repair showed a 72% rate of good to excellent results in the surgical group, compared with a 75% rate of dissatisfaction in the conservative therapy group (Arthroscopy 2007;23:118–23).

In balancing the risks of surgery, which are considered low, especially when done arthroscopically, against the risk of repeat dislocation, Dr. McCormack said the patient's lifestyle and athletic aspirations are a top consideration. “If the most aggressive thing they do is reach for the television remote, it's not a big deal, but if they're going to go back to playing football, the majority will face recurrent dislocations,” he said. “Most of the patients I see are skeletally mature, and already have an idea of how athletically demanding their lifestyle is going to be. I would be less aggressive in a 10- or 12-year-old. I wouldn't want them to redislocate six or seven times, but I would probably give them a trial of conservative therapy.”

Bracing should also be considered as an alternative to a sling in conservative management, he noted. “A sling puts the shoulder in internal rotation, but the brace causes external rotation which pulls the ligaments back so that they may hopefully heal back down in the right position.”

For patients who fail conservative management and redislocate, there is evidence that secondary surgical repair is not as effective. “Some people will never need surgery, either because they are not active enough, or they change their sport, or do well with conservative management. So by doing primary surgery, there is a chance you may overtreat.” Patients need to make their own informed decisions, balancing the risks against the benefits.

With conservative management, patients aged 40 years and older have a lower risk for redislocation, compared with younger patients, largely because the nature of the injury is usually different in this age group. “The over-40 group tends to tear their rotator cuff and younger people have Bankart lesions, where ligaments are pulled off the glenoid.”

An anteroposterior x-ray of a shoulder shows that it is dislocated anteriorly. Courtesy Dr. Robert McCormack

Physicians need a stronger message about the cardiac risks of treating chronic pain with anti-inflammatory drugs, both traditional NSAIDs and cyclooxygenase-2 inhibitors, according to Dr. Elliott M. Antman and his colleagues.

“We believe that some physicians have been prescribing COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment,” Dr. Antman, lead author of the statement, said in an interview.

He added that this approach should be adopted even for patients with no known heart risks, and caution should not be limited to the COX-2 inhibitors but extended to all NSAIDs. “The regulatory authorities have now put black box warnings on all NSAIDs, except aspirin, and even today many physicians are not aware [the warnings] exist.”

The American Heart Association statement updates the 2005 statement and reflects this new information, said Dr. Antman, professor of medicine at Harvard Medical School, Boston. But the document, which was coauthored by six cardiologists, might not sit so comfortably with physicians who treat chronic pain on a regular basis.

“I have mixed feelings about it,” said Dr. Roland Moskowitz, a rheumatologist and professor of medicine at Case Western Reserve University, Cleveland, in an interview. “I agree … you have to be cautious. But that doesn't mean we can't use these medications judiciously and appropriately. They're looking at it from the cardiologist's view when it's the rheumatologists who are sitting with the patient who is in pain.”

The AHA document outlines a stepped-care approach to the pharmacologic treatment of musculoskeletal pain in patients with known cardiovascular disease or risk factors, starting with agents that have the lowest cardiac risk. “When acetaminophen, aspirin, and perhaps even narcotic medications (for acute pain) are not effective, tolerated, or appropriate, it may be reasonable to consider an NSAID as the next step; however, this should be coupled with the realization that effective pain relief may come at the cost of a small but real increase in risk for cardiovascular or cerebrovascular complications,” wrote Dr. Antman and his colleagues (Circulation 2007 Feb. 26 [Epub DOI:10.1161/CIRCULATIONAHA.106.181424]). “If symptoms are not adequately controlled by a nonselective NSAID, subsequent steps involve prescription of drugs with increasing degrees of COX-2 inhibitory activity, ultimately concluding with the COX-2 selective NSAIDs.”

The statement outlines the spectrum of COX-2 inhibition and thus the varying degrees of cardiac and gastrointestinal risk for a wide range of NSAIDs.

Dr. Moskowitz said that most rheumatologists are already aware of the possible cardiac risks of all NSAIDs, but also have to consider gastrointestinal risks and effective pain control. “[Physicians] are frightening people away from using these things when they need to use them.”

The American College of Rheumatology's guidelines on NSAID use have not yet been updated to reflect more recent concerns about cardiovascular risk (Arthritis Rheum. 2000;43:1905–15). The Osteoarthritis Research Society International's guidelines committee, of which Dr. Moskowitz is cochair, is expected to release its recommendations on the overall management of osteoarthritis in the next few months.

Dr. Antman and his colleagues disclosed no potential conflicts of interest. Dr. Moskowitz has served as a consultant for Pfizer Inc., Novartis, Merck & Co., GlaxoSmithKline Inc., and Sanofi Aventis.

In chronic pain patients with known heart disease, 'these drugs should be the last line of treatment.' DR. ANTMAN

Physicians need a stronger message about the cardiac risks of treating chronic pain with anti-inflammatory drugs, both traditional NSAIDs and cyclooxygenase-2 inhibitors, according to Dr. Elliott M. Antman and his colleagues.

“We believe that some physicians have been prescribing COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment,” Dr. Antman, lead author of the statement, said in an interview.

He added that this approach should be adopted even for patients with no known heart risks, and caution should not be limited to the COX-2 inhibitors but extended to all NSAIDs. “The regulatory authorities have now put black box warnings on all NSAIDs, except aspirin, and even today many physicians are not aware [the warnings] exist.”

The American Heart Association statement updates the 2005 statement and reflects this new information, said Dr. Antman, professor of medicine at Harvard Medical School, Boston. But the document, which was coauthored by six cardiologists, might not sit so comfortably with physicians who treat chronic pain on a regular basis.

“I have mixed feelings about it,” said Dr. Roland Moskowitz, a rheumatologist and professor of medicine at Case Western Reserve University, Cleveland, in an interview. “I agree … you have to be cautious. But that doesn't mean we can't use these medications judiciously and appropriately. They're looking at it from the cardiologist's view when it's the rheumatologists who are sitting with the patient who is in pain.”

The AHA document outlines a stepped-care approach to the pharmacologic treatment of musculoskeletal pain in patients with known cardiovascular disease or risk factors, starting with agents that have the lowest cardiac risk. “When acetaminophen, aspirin, and perhaps even narcotic medications (for acute pain) are not effective, tolerated, or appropriate, it may be reasonable to consider an NSAID as the next step; however, this should be coupled with the realization that effective pain relief may come at the cost of a small but real increase in risk for cardiovascular or cerebrovascular complications,” wrote Dr. Antman and his colleagues (Circulation 2007 Feb. 26 [Epub DOI:10.1161/CIRCULATIONAHA.106.181424]). “If symptoms are not adequately controlled by a nonselective NSAID, subsequent steps involve prescription of drugs with increasing degrees of COX-2 inhibitory activity, ultimately concluding with the COX-2 selective NSAIDs.”

The statement outlines the spectrum of COX-2 inhibition and thus the varying degrees of cardiac and gastrointestinal risk for a wide range of NSAIDs.

Dr. Moskowitz said that most rheumatologists are already aware of the possible cardiac risks of all NSAIDs, but also have to consider gastrointestinal risks and effective pain control. “[Physicians] are frightening people away from using these things when they need to use them.”

The American College of Rheumatology's guidelines on NSAID use have not yet been updated to reflect more recent concerns about cardiovascular risk (Arthritis Rheum. 2000;43:1905–15). The Osteoarthritis Research Society International's guidelines committee, of which Dr. Moskowitz is cochair, is expected to release its recommendations on the overall management of osteoarthritis in the next few months.

Dr. Antman and his colleagues disclosed no potential conflicts of interest. Dr. Moskowitz has served as a consultant for Pfizer Inc., Novartis, Merck & Co., GlaxoSmithKline Inc., and Sanofi Aventis.

In chronic pain patients with known heart disease, 'these drugs should be the last line of treatment.' DR. ANTMAN

Physicians need a stronger message about the cardiac risks of treating chronic pain with anti-inflammatory drugs, both traditional NSAIDs and cyclooxygenase-2 inhibitors, according to Dr. Elliott M. Antman and his colleagues.

“We believe that some physicians have been prescribing COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment,” Dr. Antman, lead author of the statement, said in an interview.

He added that this approach should be adopted even for patients with no known heart risks, and caution should not be limited to the COX-2 inhibitors but extended to all NSAIDs. “The regulatory authorities have now put black box warnings on all NSAIDs, except aspirin, and even today many physicians are not aware [the warnings] exist.”

The American Heart Association statement updates the 2005 statement and reflects this new information, said Dr. Antman, professor of medicine at Harvard Medical School, Boston. But the document, which was coauthored by six cardiologists, might not sit so comfortably with physicians who treat chronic pain on a regular basis.

“I have mixed feelings about it,” said Dr. Roland Moskowitz, a rheumatologist and professor of medicine at Case Western Reserve University, Cleveland, in an interview. “I agree … you have to be cautious. But that doesn't mean we can't use these medications judiciously and appropriately. They're looking at it from the cardiologist's view when it's the rheumatologists who are sitting with the patient who is in pain.”

The AHA document outlines a stepped-care approach to the pharmacologic treatment of musculoskeletal pain in patients with known cardiovascular disease or risk factors, starting with agents that have the lowest cardiac risk. “When acetaminophen, aspirin, and perhaps even narcotic medications (for acute pain) are not effective, tolerated, or appropriate, it may be reasonable to consider an NSAID as the next step; however, this should be coupled with the realization that effective pain relief may come at the cost of a small but real increase in risk for cardiovascular or cerebrovascular complications,” wrote Dr. Antman and his colleagues (Circulation 2007 Feb. 26 [Epub DOI:10.1161/CIRCULATIONAHA.106.181424]). “If symptoms are not adequately controlled by a nonselective NSAID, subsequent steps involve prescription of drugs with increasing degrees of COX-2 inhibitory activity, ultimately concluding with the COX-2 selective NSAIDs.”

The statement outlines the spectrum of COX-2 inhibition and thus the varying degrees of cardiac and gastrointestinal risk for a wide range of NSAIDs.

Dr. Moskowitz said that most rheumatologists are already aware of the possible cardiac risks of all NSAIDs, but also have to consider gastrointestinal risks and effective pain control. “[Physicians] are frightening people away from using these things when they need to use them.”

The American College of Rheumatology's guidelines on NSAID use have not yet been updated to reflect more recent concerns about cardiovascular risk (Arthritis Rheum. 2000;43:1905–15). The Osteoarthritis Research Society International's guidelines committee, of which Dr. Moskowitz is cochair, is expected to release its recommendations on the overall management of osteoarthritis in the next few months.

Dr. Antman and his colleagues disclosed no potential conflicts of interest. Dr. Moskowitz has served as a consultant for Pfizer Inc., Novartis, Merck & Co., GlaxoSmithKline Inc., and Sanofi Aventis.

In chronic pain patients with known heart disease, 'these drugs should be the last line of treatment.' DR. ANTMAN

QUEBEC CITY — Hyperosmolar dextrose injected into ailing tendons may cause tissue damage that triggers a healing response, reported Michael Ryan, a doctoral candidate at the University of British Columbia in Vancouver.

Mr. Ryan and his coinvestigators have previously reported good to excellent outcomes with this approach, known as prolotherapy, in treating both infrapatellar and Achilles tendinopathies.

He reported on their most recent pilot investigation into the treatment of chronic plantar fasciitis at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

The study involved 23 patients with chronic plantar fasciitis (average duration, 28 months) who had failed conservative treatment. The patients had been referred to the investigators from a local sports medicine clinic. Their level of dysfunction was extremely high—some of them could not walk without a walking boot.

The patients' injured plantar fasciae, seen on ultrasound, had the characteristic features of anechoic foci, neovascularity, regions of hypoechogenicity, and calcification/cortical defects, said Mr. Ryan. The investigators injected a 50% dextrose solution diluted with 2% lignocaine into sites of palpable pain and anechoic clefts/tears using a 27-gauge needle under ultrasound guidance.

The patients received an average of five injections 6 weeks apart, for an average treatment duration of 33 weeks. At the end of that period, 14 patients reported good to excellent results, with 12 of them reporting complete resolution of symptoms and return to function.

These clinical outcomes corresponded to structural improvements seen on ultrasound, including a reduction in the number of intrasubstance tears (from 7 to 2), hypoechoic areas (from 10 to 3), calcifications (from 7 to 1), and neovascularities (from 2 to 0).

Prolotherapy, first described by Hippocrates, is thought to work by adding injury to an already injured site, so triggering the body's natural healing response.

“By creating an osmotic shock around the site of the injection, we create an inflammatory response in the tendon, which may be absent in some patients. Individuals who are 28 months symptomatic are considered to have an abnormal immune response, and this irritation stimulates healing by bringing blood to the area and releasing growth factors,” Mr. Ryan explained.

He noted that imaging may not always be necessary, which is encouraging some doctors to try prolotherapy in the primary-care setting “If the tendon is easy to palpate, such as the Achilles or the infrapatellar tendon, it's easy to find the injection spot.”

An ultrasound-guided needle delivers the dextrose: Shown here is an intratendinious tear. Courtesy Michael Ryan

QUEBEC CITY — Hyperosmolar dextrose injected into ailing tendons may cause tissue damage that triggers a healing response, reported Michael Ryan, a doctoral candidate at the University of British Columbia in Vancouver.

Mr. Ryan and his coinvestigators have previously reported good to excellent outcomes with this approach, known as prolotherapy, in treating both infrapatellar and Achilles tendinopathies.

He reported on their most recent pilot investigation into the treatment of chronic plantar fasciitis at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

The study involved 23 patients with chronic plantar fasciitis (average duration, 28 months) who had failed conservative treatment. The patients had been referred to the investigators from a local sports medicine clinic. Their level of dysfunction was extremely high—some of them could not walk without a walking boot.

The patients' injured plantar fasciae, seen on ultrasound, had the characteristic features of anechoic foci, neovascularity, regions of hypoechogenicity, and calcification/cortical defects, said Mr. Ryan. The investigators injected a 50% dextrose solution diluted with 2% lignocaine into sites of palpable pain and anechoic clefts/tears using a 27-gauge needle under ultrasound guidance.

The patients received an average of five injections 6 weeks apart, for an average treatment duration of 33 weeks. At the end of that period, 14 patients reported good to excellent results, with 12 of them reporting complete resolution of symptoms and return to function.

These clinical outcomes corresponded to structural improvements seen on ultrasound, including a reduction in the number of intrasubstance tears (from 7 to 2), hypoechoic areas (from 10 to 3), calcifications (from 7 to 1), and neovascularities (from 2 to 0).

Prolotherapy, first described by Hippocrates, is thought to work by adding injury to an already injured site, so triggering the body's natural healing response.

“By creating an osmotic shock around the site of the injection, we create an inflammatory response in the tendon, which may be absent in some patients. Individuals who are 28 months symptomatic are considered to have an abnormal immune response, and this irritation stimulates healing by bringing blood to the area and releasing growth factors,” Mr. Ryan explained.

He noted that imaging may not always be necessary, which is encouraging some doctors to try prolotherapy in the primary-care setting “If the tendon is easy to palpate, such as the Achilles or the infrapatellar tendon, it's easy to find the injection spot.”

An ultrasound-guided needle delivers the dextrose: Shown here is an intratendinious tear. Courtesy Michael Ryan

QUEBEC CITY — Hyperosmolar dextrose injected into ailing tendons may cause tissue damage that triggers a healing response, reported Michael Ryan, a doctoral candidate at the University of British Columbia in Vancouver.

Mr. Ryan and his coinvestigators have previously reported good to excellent outcomes with this approach, known as prolotherapy, in treating both infrapatellar and Achilles tendinopathies.

He reported on their most recent pilot investigation into the treatment of chronic plantar fasciitis at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

The study involved 23 patients with chronic plantar fasciitis (average duration, 28 months) who had failed conservative treatment. The patients had been referred to the investigators from a local sports medicine clinic. Their level of dysfunction was extremely high—some of them could not walk without a walking boot.

The patients' injured plantar fasciae, seen on ultrasound, had the characteristic features of anechoic foci, neovascularity, regions of hypoechogenicity, and calcification/cortical defects, said Mr. Ryan. The investigators injected a 50% dextrose solution diluted with 2% lignocaine into sites of palpable pain and anechoic clefts/tears using a 27-gauge needle under ultrasound guidance.

The patients received an average of five injections 6 weeks apart, for an average treatment duration of 33 weeks. At the end of that period, 14 patients reported good to excellent results, with 12 of them reporting complete resolution of symptoms and return to function.

These clinical outcomes corresponded to structural improvements seen on ultrasound, including a reduction in the number of intrasubstance tears (from 7 to 2), hypoechoic areas (from 10 to 3), calcifications (from 7 to 1), and neovascularities (from 2 to 0).

Prolotherapy, first described by Hippocrates, is thought to work by adding injury to an already injured site, so triggering the body's natural healing response.

“By creating an osmotic shock around the site of the injection, we create an inflammatory response in the tendon, which may be absent in some patients. Individuals who are 28 months symptomatic are considered to have an abnormal immune response, and this irritation stimulates healing by bringing blood to the area and releasing growth factors,” Mr. Ryan explained.

He noted that imaging may not always be necessary, which is encouraging some doctors to try prolotherapy in the primary-care setting “If the tendon is easy to palpate, such as the Achilles or the infrapatellar tendon, it's easy to find the injection spot.”

An ultrasound-guided needle delivers the dextrose: Shown here is an intratendinious tear. Courtesy Michael Ryan